Every finding on record at Lakeshore Manor Nursing & Rehab

Based on observations, record review and interviews, the facility failed to ensure staff:Provided residents with a clean, comfortable and homelike environment for 6 of 6 (Hall 1, Hall 2, Hall 3, Hall 4, Hall 5, and Hall 6) hallway floors; Provided a clean, comfortable and homelike environment for resident's room floor for 1 (#3) of 4 sampled residents reviewed for environmental concerns; andMaintained a resident's mattress in a sanitary manner and good condition for 1 (#3) of 4 sampled residents reviewed for environmental concerns. Findings: Review of the facility's policy dated 03/2026 and titled Resident Rights Safe, Clean and Comfortable Environment revealed the following, in part:The resident has a right to a safe, clean and comfortable environment. The facility will provide a safe, clean and comfortable environment.The facility will provide housekeeping and maintenance service necessary to maintain a sanitary, orderly and comfortable interior.The facility will provide a bed in good condition.1.An observation was made on 06/29/2026 at 10:00 a.m., during a facility tour. The floors on Hall 1, Hall 2, Hall 3, Hall 4, Hall 5, and Hall 6 had multiple dry brown, black, yellow, and tan spots and multiple scuff marks scattered throughout the hallway's floors.An observation was made on 06/30/2026 at 3:00 p.m. of the floors on Hall 1, Hall 2, Hall 3, Hall 4, Hall 5, and Hall 6. There were multiple dry, brown, black, yellow, and tan spots and scuff marks scattered throughout the aforementioned hallway's floors.An interview and observation of the facility was conducted on 07/01/2026 at 5:45 p.m. with S11HKS. During the facility tour, S11HKS confirmed there were multiple dry, brown, black, yellow, and tan spots and scuff marks scattered throughout the floors on Hall 1, Hall 2, Hall 3, Hall 4, Hall 5, and Hall 6. S11HKS confirmed the hallway floors were not a clean environment for the residents and should have been.An interview and observation of the facility was conducted on 07/01/2026 at 6:00 p.m. with S1ADM. During the facility tour, S1ADM confirmed there were multiple dry, brown, black, yellow, and tan spots and scuff marks scattered throughout the floors on Hall 1, Hall 2, Hall 3, Hall 4, Hall 5, and Hall 6. S1ADM confirmed the floors were not clean and there were spots which should not have been on the floors. S1ADM further confirmed she expected staff to have mopped and cleaned the hallway floors on a routine basis at least once a day and respond to spots as needed.2.Resident #3Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Cerebral Palsy. Review of the quarterly MDS with an ARD of 04/22/2026 revealed Resident #3 had a BIMS of 00, which indicated she was severely cognitively impaired.An observation was made on 06/29/2026 at 3:25 p.m. of Resident #3's Room A. There was a large, dry, tan substance located on the floor in between the right side of the bed and the fall mat, and under the IV pole. Located on Resident #3's fall mat was another large, dry, tan substance. An observation was made on 07/01/2026 at 8:25 a.m. of Resident #3's Room A. There was a large, dry, tan substance located on the floor in between the right side of the bed and the fall mat, and under the IV pole. Located on the fall mat there was another large, dry, tan substance. An interview was conducted on 07/01/2026 at 5:45 p.m. with S11HKS. S11HKS confirmed the above observation of the two large, dry, tan substances on the floor and on the fall mat in Resident #3's Room A. S11HKS stated the substances should have been cleaned in a timely manner but was not.An interview and observation was conducted on 07/01/2026 at 9:00 a.m. with S1ADM. S1ADM confirmed there was a dry, tan substance on the fall mat and on the floor next the bed, which should have been cleaned up. She further confirmed she expected staff to have responded to and cleaned spills in Resident #3's room as needed.3.Review of facility's policy dated 03/2024 and titled Bed Maintenance and Inspections revealed the following, in part:Mattress inspections will be conducted upon each item entering the facility and then placed on a regularly scheduled inspection and maintenance cycle. An observation was conducted on 07/01/2026 at 8:25 a.m., of a navy blue mattress with no linen in Resident #3's Room A. The center of the mattress had a large, faded, light-blue circular discoloration, marked by multiple scattered yellow, light-green, and brown spots. A few additional brown spots are scattered across the rest of the mattress surface. The mattress had a strong foul odor and 11 small bugs were flying around the discolored spots on the mattress. The middle of the mattress curved inward and created a shallow bowl-like appearance. An interview and observation was conducted on 07/01/2026 at 8:26 a.m. in Room A with S12CNA. S12CNA confirmed the mattress was faded in the middle from where Resident #3 laid. S12CNA also confirmed the mattress had green spots in the middle, and there were small bugs flying above the mattress. S12CNA stated he removed the linen off Resident #3's mattress at 8:00 a.m. today, and he did not report the status of the mattress to anyone. He confirmed Resident #3's mattress condition was not sanitary, clean, or homelike and it should have been.An interview and observation was conducted on 07/01/2026 at 8:33 a.m. S4ADON. S4ADON entered Room A and stated she had not been made aware of Resident #3's mattress condition. She confirmed Resident #3's current mattress condition was not sanitary, clean, or homelike and it should be replaced. An interview and observation was conducted on 07/01/2026 at 9:00 a.m. with S1ADM. S1ADM entered Room A and confirmed Resident #3's mattress was not clean and there were small flying insects hovering above the mattress. S1ADM further confirmed Resident #3's mattress should have been replaced because the foam in the middle of the mattress was compressed. An interview was conducted on 07/01/2026 at 9:36 a.m. with S5IPSDC. S5IPSDC stated she went to Room A and observed Resident #3's mattress condition and confirmed the mattress smelled like old urine and the mattress needed to be replaced. S5IPSDC stated she expected the CNA's to report to the nurse if a residents' mattresses was not sanitary, unclean, uncomfortable, or not in good condition. An interview was conducted on 07/01/2026 at 10:17 a.m. with S14MD. S14MD stated he and S15MA were responsible for ordering and installing new mattresses for residents. S14MD stated if there was a request for a new mattress he expected staff to notify him or S15MA verbally or logged in the maintenance binder immediately. He stated staff had not reported to him or logged in the maintenance binder an issue with Resident #3's mattress condition until after surveyor's observation on today.An interview was conducted on 07/01/2026 at 10:40 a.m. with S15MA. S15MA stated, if there was a request for a new mattress for a resident, he expected staff to notify him or S14MA immediately. S15MA stated staff had not reported to him an issue with Resident #3's mattress condition, until after surveyor's observation on today.

Based on interviews and record review the facility failed to provide the necessary treatment and services, consistent with professional standards, to promote healing and prevent the development of new pressure ulcers by failing to ensure resident's wound care was implemented as ordered for 3 (#R1, #R2, and #R3) of 8 residents reviewed for wound care management.Findings: #R1Review of Resident #R1's clinical record revealed an admission date of 08/21/2024 with diagnoses which included the following in part, Peripheral Vascular Disease, Atopic Dermatitis and Inflammatory Disorders of Scrotum. Review of Resident #R1's current physician orders revealed in part, the following:Start Date: 04/24/2025- MedCentris to evaluate and treatStart Date: 03/20/2026- Calcium Alginate-Silver External Pad 4-Apply to left groin topically every day shift every Monday, Wednesday, Friday for Abscess. Clean wound bed with wound cleaner, apply silver alginate and cover with Optilock absorbent padStart Date: 06/23/2026- Wound care steps-1-evalaute patients back and skin tears 2- cleanse wound site 3- Apply Mepilex- One time a day Review of Resident #R1's current care plan revealed in part, the following:Focus: Risk for skin breakdown r/t impaired mobility, history of wounds, dry skin Intervention/Tasks: Administer treatments as ordered and monitor for effectiveness. Notify MD for worsening or stalled wounds.Focus: R1 has a stage 3 pressure ulcer to the left gluteus Intervention/Tasks: Wound/Skin care per Physician orderFocus: The resident has MASD to sacrum and spine Review of Resident #R1's June 2026 Medication Administration Record (MAR) revealed the following:06/26/2026-assigned nurse- S8LPN, no documented evidence wound care performedOn 07/01/2026 at 11:15 a.m., an interview was conducted with S8LPN. She reviewed Resident #R1's June 2026 MAR and confirmed she was Resident #R1's assigned nurse on 06/26/2026. S8LPN confirmed Resident #R1's wound care on 06/26/2026 was not performed because she had not been provided any education on wound care management by provider. S8LPN stated she did not feel comfortable performing wound care as she feared she would lose her nursing license if she performed inadequate wound care to residents. #R2Review of Resident #R2's clinical record revealed an admission date of 09/11/2018 with diagnoses which included the following in part, Hemiplegia and Hemiparesis Affecting Right Dominant Side and Type II Diabetes Mellitus. Review of Resident #R2's current physician orders revealed in part, the following:Start Date: 05/02/2025- MedCentris Evaluate and TreatStart Date: 05/28/2026-Collagen Matrix-Silver External Sheet 2- Apply to right buttock topically every day shift Monday, Tuesday, Thursday for Pressure 2.Clean wound bed with wound cleanser , apply silver collagen to wound bed and cover with silicone foam border. Review of Resident #R2's current care plan revealed in part, the following:Focus: Resident #R2 has a Stage 2 pressure ulcer to right gluteus r/t impaired mobility and incontinenceIntervention/Tasks: Apply wound treatment/dressing per provider orders Review of Resident #R2's June 2026 MAR revealed the following:06/04/2026 -assigned nurse- S6LPN, no documented evidence wound care performed06/11/2026-assigned nurse-S8LPN, no documented evidence wound care performed06/16/2026-assigned nurse-S6LPN, no documented evidence wound care performed06/25/2026-assigned nurse-S8LPN, no documented evidence wound care performed #R3Review of Resident #R3's clinical record revealed an admission date of 09/03/2021 with diagnoses which included the following in part, Cellulitis, Xerosis Cutis, and Rash with Other Nonspecific Skin Eruption. Review of Resident #R3's current physician orders revealed in part, the following:Start Date: 05/05/2026- Cleanse Left posterior thigh with wound cleanser, apply silver collagen to wound bed, gentian violet to peri-wound and cover with silicone foam border every day shift every Monday, Tuesday, Thursday for skin tear abrasion. Review of Resident #R3's current care plan revealed in part, the following:Focus: Resident #R3 has an abrasion to left posterior thighFocus: Resident #R3 has potential for pressure ulcer development r/t impaired mobility, incontinence, history of skin irritation Intervention/Tasks: Administer treatments as ordered and monitor for effectiveness Review of Resident #R3's June 2026 MAR revealed the following:06/04/2026 -assigned nurse- S6LPN, no documented evidence wound care performed06/11/2026-assigned nurse-S8LPN, no documented evidence wound care performed06/16/2026-assigned nurse-S6LPN, no documented evidence wound care performed06/25/2026-assigned nurse-S8LPN, no documented evidence wound care performed On 07/01/2026 at 11:15 a.m., an interview was conducted with S8LPN. She reviewed Resident #2's and #R3's June 2026 MAR and confirmed she was Resident #R2's and #R3's assigned nurse on 06/11/2026 and 06/25/2026. S8LPN confirmed Resident #R2's and #R3's wound care on 06/11/2026 and 06/25/2026 was not performed because she had not been provided any education on wound care management by provider. S8LPN stated she did not feel comfortable performing wound care as she feared she would lose her nursing license if she performed inadequate wound care to residents. On 07/01/2026 at 12:15 p.m. a telephone interview was conducted with S6LPN. S6LPN confirmed she was Resident #R2's and #R3's assigned nurse on 06/04/2026 and 06/16/2026. S6LPN stated on 06/04/2026 she was unaware wound care was to be performed by floor nurse. S6LPN stated on 06/16/2026 due to the high acuity of her assigned hall, she was unable to complete daily wound care task for Resident #R2 and #R3 and reported this to oncoming shift and placed on 24 hour report sheet. S6LPN stated a blank on the Medication Administration Record meant the task wasn't completed or signed off on. On 07/01/2026 at 12:50 p.m., an interview was conducted with S3ADON. She reviewed the aforementioned June 2026 (MAR) for Resident #R1, #R2 and #R3. S3ADON stated a blank on the MAR indicated a task was not completed and signed off on. S3ADON stated if a task wasn't documented or signed off it was considered not done. S3ADON stated she expected her nursing staff to sign off on task when completed.On 07/01/2026 at 1:30 p.m., an interview was conducted with S2IDON. She reviewed the aforementioned June 2026 MAR for Resident #R1, #R2 and #R3. S2IDON stated a blank on the MAR indicated a task was not completed and signed off on. S2IDON stated if a task wasn't documented or signed off it was considered not done. S2IDON confirmed all residents should be provided the necessary treatment and services, consistent with professional standards, to promote healing and prevent the development of new pressure ulcers.

Based on interviews the facility failed to ensure 4 (S7LPN, S8LPN, S9LPN and S10LPN) of 4 LPNs reviewed for wound care had the competencies and skill sets to provide wound care to residents. Findings: On 06/30/2026 at 9:30 a.m., an interview was conducted with S10LPN. S10LPN stated he provided wound care to his assigned Residents who required wound care management services. S10LPN stated the provider had not assessed his competencies or provided training prior to assigning residents with wound care. On 07/01/2026 at 11:15 a.m., an interview was conducted with S8LPN. She stated she had limited clinical experience due to being a recent graduate. She denied having any certifications or educational background in wound care management. She stated she did not feel comfortable providing wound care without the proper education and training. She stated the provider had not assessed her competencies or provided training prior to assigning her to complete wound care management for residents. She voiced concern that if she provided wound care incorrectly and had an adverse outcome she could lose her nursing license. On 07/01/2026 at 4:40 p.m., an interview was conducted with S7LPN. S7LPN stated she provided wound care to her assigned Residents who required wound care management services. She denied having any certifications or educational background in wound care management. S7LPN stated the provider had not assessed her competencies or provided training prior to assigning her to complete wound care management for residents. On 07/01/2026 at 5:45 p.m., an interview was conducted with S9LPN. S9LPN stated she provided wound care to her assigned Residents who required wound care management services. She denied having any certifications or educational background in wound care management. S9LPN stated the provider had not assessed her competencies or provided training prior to assigning her to complete wound care management for residents. S9LPN stated she didn't feel comfortable providing wound care to residents due to lack of education and training in wound management procedure and protocols. On 07/01/2026 at 11:10 a.m., an interview was conducted with S5IPSDC. She stated wound care responsibilities had recently been assigned to the floor nurses after the facility eliminated the wound care nurse position. She confirmed S7LPN, S8LPN, S9LPN and S10LPN were floor nurses that would be required to perform wound care. S5IPSDC stated the provider had not assessed competencies or provided training in wound care management for S7LPN, S8LPN, S9LPN and S10LPN. On 07/01/2026 at 4:10 p.m., an interview was conducted with S2IDON. She stated nursing staff were not provided education or trainings in wound care management prior to being assigned the task of performing daily wound care to assigned residents. S2IDON confirmed the provider had no competency assessments or evaluations for S7LPN, S8LPN, S9LPN and S10LPN to provide wound care management for residents.

Based on record review and interviews, the facility failed to ensure a resident was free of significant medication errors by not providing medication administration in accordance with accepted professional nursing standards for 1 (#1) of 4 residents' MARs reviewed.Findings: Review of the facility's undated policy titled Job Description Licensed Practical Nurse revealed the following, in part:Pharmacy knowledge:Demonstrate a knowledge of drug reactions and sensitivities and nursing interventions. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, in part, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Further review revealed Resident #1's allergies included Amoxicillin. Review of Resident #1's current Physician Orders, as of 06/29/2026, revealed the following antibiotic:Start date 06/28/2026. Amoxicillin-Pot Clavulanate tab 875-125mg, 1 tab via PEG tube every 12 hours for dental infection for 7 days. Discontinued-06/30/2026.Further Review revealed the following antibiotic was added to Resident #1's medication regimen:Start Date 06/30/2026. Cephalexin Suspension Reconstituted 250 mg/5ml Give 10 ml via PEG-tube every 6 hours for infection for 7 Days. Review of Resident #1's MAR dated June 2026 revealed Amoxicillin-Pot Clavulanate tab 875-125mg antibiotic medication administered on the following dates and times:06/28/2026 at 8:00 a.m. and 8:00 p.m.; and06/29/2026 at 8:00 a.m. Review of Resident #1's Nurses Notes revealed the following, in part: Date-06/29/2026-Author- S7LPN- Resident was started on Amoxicillin 875- 125 for DX Tooth Abscess. Resident noted to have itching allergy reaction to this medication, NP was made aware of this and medication discontinued and new order for Keflex put in place for Tooth abscess. Resident's RP.called and notified . Resident had no adverse reactions throughout shift from medication. No itching or swelling or other adverse reactions noted. Resident also made aware of medication change. Respirations even and unlabored. No s/s of any respiratory distress noted. Resident remained in stable condition throughout shift . An interview was conducted on 06/30/2026 at 11:18 a.m. with S16LPN. S16LPN stated, on 06/28/2026, she gave the first Amoxicillin-Pot Clavulanate dose to Resident #1. S16LPN stated she acquired the first two doses of Amoxicillin-Pot Clavulanate out of the facility's emergency kit because the next pharmacy delivery would be Monday afternoon. S16LPN stated she did not call the doctor before she administered the Amoxicillin-Pot Clavulanate for Resident #1. She further confirmed she should have looked at Resident #1's allergies before Amoxicillin-Pot Clavulanate was administered to Resident #1 and did not. An interview was conducted on 07/01/2026 at 4:30 p.m. with S7LPN. S7LPN stated, on 06/29/2026 at 6:00 a.m., she gave Amoxicillin-Pot Clavulanate to Resident #1. S7LPN stated on 06/29/2026 the pharmacy called her and notified her of the Amoxicillin-Pot Clavulanate allergy. S7LPN stated she called the on call provider for order clarification. She stated Resident #1 had an itching reaction to the Amoxicillin-Pot Clavulanate medication. S7LPN confirmed she did not look at Resident #1's allergies before she administered the Amoxicillin-Pot Clavulanate medication, and she should have. An interview was conducted on 07/01/2026 at 1:03 p.m. with S2IDON. S2IDON confirmed she expected nursing staff to review residents' allergies before administering medication and review the electronic health record system allergy alerts to identify any discrepancies. S2IDON further confirmed when an allergy to an ordered medication is identified, she expected the nurse to call the ordering provider to clarify if the prescribed medication should be given or discontinued and to document the notification in the nurses notes.

Based on record review and interviews, the facility failed to ensure a resident received ADL care in accordance with professional standards of practice and the comprehensive person-centered care plan for Resident 1 (#4) of 4 residents reviewed for ADL care.Findings: Review of the facility's policy dated 03/2026 and titled Quality of Life Activities of Daily Living/ Maintain Abilities revealed the following, in part:Facility provides necessary care and services to support the resident's needs. Review of Resident #4's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Generalized Muscle Weakness, Lack of Coordination, and Difficulty in Walking. Review of Resident #4's current MDS revealed she had a BIMS of 14, which indicated she was cognitively intact. Review of Resident #4's most recent Care Plan revealed the following, in part:Problem: Self-care Deficit Approaches: Toileting- totally dependent An interview was conducted on 06/30/2026 at 5:00 p.m. with Resident #4. She stated she notified a CNA she needed her soiled brief to be changed. She stated she had to sit in her soiled brief for 4 hours until she was changed by staff. She stated 4 hours was too long for her to wait to be changed. An interview was conducted on 06/30/2026 at 11:18 a.m. with S16LPN. S16LPN stated she reported Resident #4's ADL care needs to S17CNA on 06/13/2026 and informed her of Residents increase in bladder urgency requiring more frequent brief changes. S16LPN stated when she returned to work on 06/14/2026, Resident #4's brief was observed to be soiled and bed sheets were saturated with urine. An interview was conducted on 07/01/2026 at 2:18 p.m. with S17CNA. S17CNA stated she was Resident #4's assigned aide 3 weeks ago. S17CNA stated Resident #4 pressed the call light and voiced needing to be changed. S17CNA stated she forgot to return to Resident #4's room to change her because she got busy providing care to other Residents and had to respond to other call light needs. S17CNA stated Resident #4 was not changed for more than 2 hours. S17CNA stated Resident #4 should have been changed in a timely manner and was not. An interview was conducted on 07/01/2026 at 6:15p.m.with S2IDON. S2IDON stated she expected CNAs to round every 2 hours to provide incontinence care to residents. She confirmed it was not acceptable for a resident to have to wait more than 2 hours to be changed.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers. The facility failed to ensure heel protectors were placed on a resident per Physician's Orders for 1 (#3) of 3 sampled residents. Findings: Review of the facility's Skin Integrity Policy dated 05/2026 revealed the following, in part:Policy Statement:The facility, based on a resident's comprehensive assessment, will provide care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing, prevent infection and prevent new ulcers from developing unless the resident's clinical condition demonstrates that they were unavoidable. Policy Components:5. A resident identified as at risk of developing impaired skin integrity will have individualized interventions implemented to attempt to prevent areas of skin integrity impairment from developing. Review of Resident #3's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction and Mild-Protein Calorie Malnutrition. Review of Resident #3's Braden Evaluation dated 04/23/2026 revealed a score of 10. Further review revealed a total score of 12 or less represented high risk for skin breakdown. Review of Resident #3's active Physician's Orders revealed the following, in part:Bilateral heel protectors at all times. Revision date 05/07/2025. On 05/12/2026 at 8:15 a.m., an observation was made of Resident #3. He was sitting up in his geri-chair with his eyes closed. He was not wearing bilateral heel protectors. On 05/12/2026 at 12:35 p.m., an observation was made of Resident #3. He was sitting up in his geri-chair watching television. He was not wearing bilateral heel protectors. On 05/12/2026 at 1:51 p.m., an observation was made of Resident #3. He was lying in bed. He was not wearing bilateral heel protectors. His bilateral lower extremities were observed to be directly on the mattress. On 05/13/2026 at 11:00 a.m., an interview was conducted with S2CNA. She verified she was assigned to Resident #3 on 05/12/2026. She stated Resident #3 did not have heel protectors as a pressure ulcer intervention. She confirmed Resident #3 was not wearing heel protectors on 05/12/2026 during her shift. On 05/13/2026 at 2:15 p.m., an interview was conducted with S3CNA. He stated he had been assigned to Resident #3 multiple times and was familiar with him. He stated Resident #3 did not have heel protectors as a pressure ulcer intervention. He confirmed Resident #3 never wore heel protectors on any of the shifts he was assigned to Resident #3. On 05/13/2026 at 12:35 p.m., an interview was conducted with S2DON. She confirmed if a resident had heel protectors ordered, the heel protectors should have been placed on the resident.

Based on observations, interviews, and record reviews, the facility failed to implement its written abuse policy to prevent resident abuse, neglect, exploitation and misappropriation of property by failing to ensure employment screening was completed for 1 (S12) of 1 unknown alleged agency staff. On [DATE], S12, who was not employed by the facility or staffing agency, was assigned to provide direct care to residents R1, R2, R3, R4, R5, R6, R7, R8, R9 and R10 without being screened for a history of abuse, neglect, exploitation or misappropriation of property. An Immediate Jeopardy situation began on [DATE] at 8:00 a.m. when S12, who was not employed by the facility or staffing agency, presented herself to S10LPN, S11LPN, and S13LPN stating she was a staffing agency CNA arriving to cover an open shift. Facility staff failed to ensure S12 was sent by the staffing agency and screened prior to being assigned direct care of residents. From approximately 8:30 a.m. to 10:30 a.m. S12 was assigned to provide direct care to residents R1, R2, R3, R4, R5, R6, R7, R8, R9 and R10. Due to the facility's ineffective system to ensure only qualified nursing personnel were assigned to care for residents; residents R1, R2, R3, R4, R5, R6, R7, R8, R9 and R10 were placed at a likelihood of serious harm, injury, impairment, or death from occurring. S1ADM was notified of the Immediate Jeopardy on [DATE] at 4:41 p.m.Findings:Cross Reference: F835 Review of the facility's revised policy dated 03/2025 and titled, Freedom From Abuse, Neglect, and Exploitation, Preventing and Prohibiting Abuse revealed, in part:Guidelines:1. The facility will maintain and implement policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, and misappropriation of resident property.2. The policies and procedures will include the following components:a. ScreeningSCREENING2. Potential employees will be screened with the appropriate licensing/certification boards, in various/multiple states when applicable.3. When possible, previous and/or current employers should be contacted to obtain a reference for a potential employee.4. Facility will conduct a criminal background check on potential employees who have been deemed qualified for hire.5. The facility will not employ an individual whose pre-employment screening indicates a criminal or licensing/certification board history of abuse, neglect, or misappropriation of property.6. The facility will report to the state nurse aide registry or other licensing authorities any knowledge of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff screening.7. Contracted staff, temporary staff will be screened by a third-party agency or academic institution according the same or substantially similar guidelines as above. Review of the facility's Daily Assignment sheet dated [DATE] revealed S12's name was hand written and assigned to provide care to Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10. Review of Resident #R1's clinical record revealed he was admitted to the facility on [DATE] with a primary diagnosis Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Review of Resident #R2's clinical record revealed he was readmitted to the facility on [DATE] with a primary diagnosis Hemiplegia and Hemiparesis Following Other Cerebrovascular Disease Affecting Left Non-Dominant Side. Review of Resident #R3's clinical record revealed he was readmitted to the facility on [DATE] with a primary diagnosis Chronic Obstructive Pulmonary Disease with Acute Exacerbation. Review of Resident #R4's clinical record revealed he was readmitted to the facility on [DATE] with a primary diagnosis Gastrostomy Malfunction. Review of Resident #R5's clinical record revealed he was readmitted to the facility on [DATE] with a primary diagnosis Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side. Review of Resident #R6's clinical record revealed he was admitted to the facility on [DATE] with a primary diagnosis Unspecified Atrial Fibrillation. Review of Resident #R7's clinical record revealed she was readmitted to the facility on [DATE] with a primary diagnosis Non-Traumatic Subarachnoid Hemorrhage, Unspecified. Review of Resident #R8's clinical record revealed he was admitted to the facility on [DATE] with a primary diagnosis Hypertensive Urgency. Review of Resident #R9's clinical record revealed he was readmitted to the facility on [DATE] with a primary diagnosis Acute Infarction of Spinal Cord (Embolic) (Non-Embolic). Review of Resident #R10's clinical record revealed he was readmitted to the facility on [DATE] with a primary diagnosis Encephalopathy, Unspecified. An observation and interview was conducted on [DATE] at 10:26 a.m. with S12. S12 was observed walking up to the main hallway near the gym and appeared very anxious, speaking very loudly, repeating I want to speak to the State, I know they are here. Surveyor identified self and S12 agreed to an interview. S12 stated she was not employed by the facility or a staffing agency. S12 then explained she entered the facility at 8:00 a.m. and inquired if there were any job openings. She said S14CNA then allowed her entry into the locked building and directed her to the nurses' station in the back of the facility to speak with S10LPN or S13LPN. S12 stated when she arrived to the nurse's station, S10LPN told her we need a CNA on the hall and asked her to change her shoes from flip flops to tennis shoes. S12 stated she then left the facility to change her footwear and returned within 5-10 minutes around 8:30 a.m. S12 stated S9R allowed reentry into the building. S12 said she then told S10LPN, S11LPN and S13LPN she was agency staff reporting for the open shift. S12 stated S11LPN gave her a temporary ID badge and assigned her to provide care to R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10. S12 stated she rounded, answered call lights, and went to the kitchen to obtain snacks for a couple of residents. S12 stated she answered the call light for Resident R4. S12 said she donned a gown and gloves because barrier precaution signage was posted outside the room, then entered the room and asked Resident R4 what he needed. S12 stated she then asked for S18CNA and S19CNA's assistance to help her after she touched Resident R4, rolled him over to remove his brief, and her gloved hand and gown sleeve became soiled with feces. S12 stated she then removed the soiled gloves and gown and left the room. S12 stated she became upset when S10LPN paged her, then approached S12 in the hallway, and asked where she had been. S12 stated she had then walked off the hall assignment, got a snack, and looked for the state surveyor. S12 stated S10LPN followed her down the hall and said You need to clock out. S12 then responded, I'm not clocked in. S12 confirmed S10LPN, S11LPN, and S13LPN were aware she had worked on the hall assignment, and at no point did any facility staff verify her identity or credentials prior to assigning resident care. An interview was conducted on [DATE] at 11:15 a.m. with S19CNA. S19CNA verified he had provided care for Resident #R4 earlier this morning with S12 present. S19CNA confirmed S12 had entered Resident #R4's room and came to the doorway and asked for his and S18CNA's assistance. S19CNA stated when he and S18CNA went into Resident #R4's room, S12 immediately removed her gloves and gown and said she had to leave to go wash her hands. S19CNA stated S12 never returned to Resident #R4's room. S19CNA stated he was unaware if S12 was facility or agency staff. An interview was conducted on [DATE] at 11:20 a.m. with S18CNA. S18CNA verified he had provided care for Resident #R4 earlier this morning with S19CNA. S18CNA confirmed he and S19CNA had completed incontinence care for Resident #R4 after S12 removed her gloves and gown and left the resident's room and never came back. S18CNA stated he had never worked with S12 and was unaware if she was facility staff or agency staff. Review of the facility's Visitor log sheet for [DATE] revealed S12 was not listed. Review of the facility's personnel list revealed S12 was not a current employee. An interview was conducted with S26BC on [DATE] at 11:25 a.m. S26BC stated she was responsible for ensuring agency staff were screened with registry information reviewed prior to being assigned to care for residents. S26BC confirmed S12 was not a current employee of the facility. S26BC verified the facility had not obtained or performed any screening verification of S12's registries or background check before S12 was assigned to care for residents on [DATE], and the facility staff had not provided orientation or completed a competency evaluation prior to S12's assignment. S26BC confirmed there was no current process for screening or onboarding agency staff upon entry into the facility prior to starting each shift. An interview was conducted with Resident #R4 on [DATE] at 9:20 a.m. Resident #R4 confirmed a female answered his call light yesterday morning, but didn't identify herself. Resident #R4 stated the female went to the door and asked 2 male CNA's from the hallway to come assist to change his brief. Resident #R4 confirmed the unknown female was dressed in a gown and gloves and left his room after she said her gloves and gown were soiled. Resident #R4 stated the female aide never removed his brief and never returned to his room. An interview was conducted with S13LPN on [DATE] at 11:27 a.m. S13LPN verified S12 presented herself as agency staff today around 8:30 a.m. with S10LPN present. S13LPN said S12 was asked if she was agency staff, and S12 responded yes. S13LPN stated she nor S10LPN verified if S12 was agency staff nor did they verify her credentials prior to S11LPN assigning S12 to the daily schedule to provide care for Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10. S13LPN confirmed the facility had no current process to screen or provide orientation and competency evaluations of agency staff once they enter the facility for their shift. S13LPN stated agency staff are expected to report to any hall, clock in through their agency on their cell phones, and look at the daily assignment sheet for their assigned residents. S13LPN stated agency staff do not receive facility orientation to review the facility's policy and procedures, abuse/neglect training, or complete a competency evaluation prior to assigning resident care. An interview was conducted with S11LPN on [DATE] at 12:06 p.m. S11LPN verified she was approached by S12 this morning around 8:30 a.m. at the nurse's station, and S12 stated she was agency staff reporting for her shift. S11LPN stated she did not verify S12 was agency staff or ensure S12 had been screened, oriented to the facility, or deemed competent prior to assigning her to care for Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10. An interview was conducted with S10LPN on [DATE] at 12:24 p.m. S10LPN verified S12 presented herself as agency staff today reporting for an assignment around 8:30 a.m. S10LPN confirmed the facility did not verify S12 to ensure she was agency staff. S10LPN said S11LPN assigned S12 to provide resident care to Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10 without ensuring S12 had been screened, oriented to facility policy and procedures or deemed competent to do so. S10LPN stated the facility utilized agency staff often. S10LPN stated S25S would requests all open shifts with the staffing agency during the week, and the nursing administration on-call staff were responsible for requesting staff after-hours and on weekends/holidays. S10LPN stated all agency staff should be pre-approved by either S25S or administrative staff, with verification of credentials and screening prior to adding the agency staff to the facility's daily shift schedule. S10LPN confirmed the facility had no current orientation process for onboarding agency staff. An interview was conducted with S2DON on [DATE] at 11:56 a.m. S2DON said S10LPN, S11LPN, and S13LPN reported S12 identified herself as agency staff reporting for duty around 8:30 a.m. S2DON stated S12 was then assigned to provide care to Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10. S2DON confirmed she, S25S, nor any other administrative staff had verified S12's credentials or screening, and S12 was allowed to care for Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10 from 8:30 a.m. to approximately 10:30 a.m. S2DON confirmed S12 should not have been allowed to provide resident care without verification of her agency identification, registries, and background check credentials. S2DON confirmed the facility had no current orientation process for onboarding agency staff. An interview was conducted with S1ADM on [DATE] at 4:15 p.m. S1ADM confirmed S12 was not currently employed with the facility or the staffing agency the facility utilized as of [DATE]. S1ADM confirmed S12 should not have been allowed to provide care to residents residing in the facility without being screened. The Immediate Jeopardy was removed on [DATE] at 4:59 p.m., after it was determined through observation, interviews, and record review; that the facility implemented an acceptable Plan of Removal prior to the survey exit, which included:1. Immediate Action Taken to Remove the Immediate JeopardyOn [DATE], the facility became aware that an individual presented herself as agency staff and entered the facility without verification of employment or credentials. Immediate action was taken to ensure the individual was no longer present and to secure the building.On [DATE], the management team conducted an immediate search of the facility to locate the individual and confirmed she was no longer present in the building. The facility verified with the staffing agency that the individual was not employed by the agency and, through the facility staffing system, confirmed that she was neither an active nor a former employee. The receptionist and front desk staff were immediately instructed not to allow the individual entry should she return. Administration searched the parking lot to ensure the individual had left the premises.On [DATE], the facility contacted the Police Department, who responded at approximately 5:15 p.m. to document the incident, and obtained identifying information. A photograph of the individual was printed and displayed throughout the facility with instructions to contact law enforcement if she returned.On [DATE] at 5:30 p.m., a 24-hour door monitor was immediately established to ensure that all individuals entering the facility are identified, verified, and logged prior to entering the building.These actions immediately removed the potential for the unidentified individual to access residents.2. Identification of Residents Who Were Potentially AffectedOn [DATE], at approximately 12:00 p.m. the facility evaluated residents who could have potentially been affected.On [DATE], at approximately 12:00 p.m. residents residing in the area where the individual's name had been placed on the assignment sheet were interviewed to determine whether the individual provided care or engaged in any abusive behavior. No residents reported receiving care from the individual or experiencing abuse.To ensure the protection of all residents in the facility:On [DATE], starting at approximately 8:00 p.m., all residents with a BIMS score of 8 or greater were interviewed regarding any concerns related to abuse, neglect, or mistreatment.Residents with a BIMS score of less than 8 received a head-to-toe assessment by a licensed nurse to evaluate any signs or symptoms of abuse.All interviews and assessments will be completed on [DATE] by 6:00 p.m.No findings of abuse, injury, or concerns were identified.3. Systemic Corrective Actions ImplementedSystem for Verification of Employee and Agency Staff Credentialing Prior to WorkingTo ensure only properly screened, credentialed, and eligible staff are permitted to work in the facility, the following process has been implemented and will be followed for all facility employees and all agency/contract staff prior to assignment and prior to the start of each shift:1. Pre-Employment Screening for Facility EmployeesPrior to hire and prior to the employee being permitted to work in the facility, the facility will complete and verify all required pre-employment screening consistent with the facility's Freedom from Abuse, Neglect and Exploitation - Abuse Policies (1112017), Revised V2 (03/2025), including:Interview of the applicant prior to hire.Review and screening of employment history.Verification with the appropriate licensing and/or certification board(s), including multiple states when applicable.Reference checks with prior and/or current employers, when possible.Criminal background check for applicants deemed qualified for hire.Review of all screening results to ensure there is no history of abuse, neglect, exploitation, misappropriation of property, or other disqualifying findings.Confirmation that the individual is eligible to work in the position for which they are hired.No employee will be permitted to begin orientation, resident care duties, or any work assignment until all required screenings have been completed and cleared.2. Verification of Active License/Certification Prior to StartFor any position requiring a professional license or certification, the facility will verify that the credential is current, active, and in good standing prior to the staff member's first shift. This includes, as applicable:CNA certificationNursing licenseOther professional license, certifications, or registration required for the assigned roleDocumentation of the verification will be maintained in the employee file and/or credentialing log.3. Final Clearance by Designated Facility LeadershipThe Administrator, DON, Staff Development Coordinator, Human Resources designee, and other assigned leadership personnel will review the completed pre-employment screening packet prior to clearing the individual to work. This review will confirm:Background screening is completeLicense/certification verification is completeReferences were obtained when possibleNo exclusionary findings are presentEmployee meets facility requirements to workOnly after this review is complete will the employee be marked as cleared for scheduling.4. Agency Staff Credentialing Verification Prior to SchedulingFor all contracted, temporary, and agency staff, the facility scheduler and/or designee will verify with the staffing agency that the agency staff member has been screened according to the same or substantially similar standards as facility employees, including:License/certification verificationBackground screeningReview for abuse, neglect, exploitation, or misappropriation findingsConfirmation that the staff member is eligible and qualified to work in the assigned roleThe scheduler or designee will obtain and maintain agency confirmation of credentialing prior to placing the individual on the facility schedule.5. Placement on Schedule Only After VerificationNo employee or agency staff member will be placed on the daily work schedule until the required credentialing and screening verification is completed.For facility staff, clearance must be confirmed by facility leadership.For agency staff, clearance must be confirmed with the staffing agency and documented by the scheduler/designee.If updated or new staffing changes occur after the schedule is prepared, the same verification process will be completed before the staff member is allowed to work the shift.6. Daily Schedule Review Prior to Each ShiftPrior to the start of each shift, the facility will review the daily staffing schedule to ensure that all scheduled staff have been cleared up to work.This review will include:Confirmation that facility employees scheduled have completed the required screening and credentialingConfirmation that agency staff added to the schedule have documented verification from the agency.Review of any call-ins, replacements, or schedule changes to ensure newly added staff are verified prior to workingAny staff member whose credentials, screening, or eligibility cannot be verified will not be permitted to work until verification is completed.7. Facility Entry Validation at Start of ShiftUpon arrival at the facility, the designated 24/7 door monitor/trained staff person will validate each facility employee and each agency staff member entering the facility by:Reviewing name badge/identificationConfirming the individual matches the daily schedule or approved staffing listRequiring the individual to sign the daily staff log upon entryIf the individual's identity, status, or authorization to work cannot be confirmed, the person will be held from entering resident care areas, and immediate follow-up will occur with the scheduler, DON, or Administrator.8. Real-Time Follow-Up for Any Unverified StaffIf at any point a facility employee or agency staff member presents to work and verification is incomplete, missing, or inconsistent, the individual will not be permitted to provide resident care or work in the facility until verification is obtained.The Administrator, DON, scheduler, or designee will immediately:Re-check internal credentialing records and/or personnel fileContact the staffing agency, if applicableValidate active licensure/certification, if applicableDetermine whether the individual is eligible to workIf verification cannot be confirmed, the staff member will be removed from the schedule and replaced.9. Ongoing Monitoring of Expirations and ChangesThe facility will maintain an ongoing system to monitor employee and agency credentials for expiration or status changes. This process will include periodic review of:License expiration datesCertification expiration datesAgency roster updatesAny reports or findings that may affect staff eligibilityAny employee or agency staff member with expired or unverifiable credentials will be removed from assignment until the issue is resolved.10. Accountability and DocumentationThe facility will maintain documentation of all credentialing verification activities, including:Employee screening recordsLicense/certification verification recordsAgency verification recordsDaily staff logsSchedule review documentation, as applicableThe Administrator and DON will be responsible for oversight of compliance with this process. Any identified failures in pre-work verification will be addressed immediately through corrective action, re-education, and monitoring.IIS Audit and Compliance MonitoringTo ensure sustained compliance, the regional staff will audit this process routinely for both facility and agency staff. Audits will include a review of:Staff on schedule versus staff cleared to workAgency staff verification documentationDaily entry logsActive license/certification status for licensed/certified staffAny variance identified through audit will be corrected immediately and trended through the facility's QAPI process.This process was implemented immediately to ensure that no facility employee or agency staff member is permitted to work without prior verification of screening, credentialing, and authorization, and to provide ongoing shift-by-shift validation that only approved personnel are allowed to enter and work in the facility.The facility implemented the following systemic corrective actions to ensure the noncompliance does not recur:On [DATE], at 4:45 p.m., a trained facility employee door monitor was implemented 24 hours per day to ensure all people entering the facility are verified.All people, including staff, entering the facility are required to sign in and out at the front desk.On [DATE], the front desk will not be left unattended, and staff coverage has been arranged to ensure continuous monitoring.Keypad door codes were changed throughout the facility: Starting [DATE] at 4:00 p.m. and completed on [DATE] to prevent unauthorized access. All previously stored codes were deleted, and new codes were input.Additionally, education for all staff in all departments began on [DATE] by the Staff Development Coordinator (SDC) at approximately 5:00 p.m. regarding:Abuse, neglect, and exploitation preventionStaff responsibility to identify and report unknown individualsVerification of agency staff with verification of licensing boards and registries will be completed by the scheduler and or the Payroll Benefits coordinator (PBC) and maintained on file with the facility prior to providing resident care.The facility will verify abuse training requirements are met by obtaining a copy of the training from the agency and providing the abuse training at the beginning of their first scheduled shift with the facility.Facility entry procedures and sign-in requirementsEducation for all staff will be completed by the Staff Development Coordinator (SDC) orDesignee on [DATE] at 11:00 p.m. Staff who are not present during initial education will receive education prior to their next scheduled shift.Competency Validation following the abuse prevention education, the Director of Nursing, Unit Managers, and Department Managers validated staff competency through verbal return demonstration and staff interviews. Staff were required to verbally explain:What constitutes abuse, neglect, and misappropriation of resident property. The requirement to immediately report any allegation or suspicion of abuseThe facility's reporting chain of commandsStaff who were unable to accurately verbalize the required reporting process received immediate re-education prior to returning to resident care duties.In addition, supervisory staff will conduct random staff interviews during rounds to confirm ongoing staff knowledge of abuse reporting requirements, and results will be monitored through the facility's Quality Assurance and Performance Improvement (QAPI) process.4. Monitoring to Ensure Ongoing ComplianceThe facility will monitor compliance with these corrective actions to ensure ongoing protection of residents.Nursing The Administrator and Director of Nursing will monitor the entry log and door monitoring process daily x 12 weeks and ongoing to ensure all individuals entering the facility are properly verified.Leadership will conduct random audits of the sign-in log and staffing assignments daily x 4 weeks, 3xweek x 4 weeks, weekly x 4 weeks and ongoing to ensure only verified staff are providing resident care.Verification of agency staff credentials and employment status [NAME] be completed prior to any agency staff member providing resident care by Scheduler/Payroll Benefits Coordinator.The verification of agency staff credentials and employment status is completed by the scheduler for nights and the DON on weekends. The Manager on Duty and the Nurse Supervisor complete the training on abuse with the agency staff secured for nights or weekends. The facility asserts that the likelihood of serious injury, serious harm, serious impairment, or death to residents no longer exists as of [DATE]. The deficient practice continued at a potential for more than minimal harm for the 83 residents residing in the facility.

Based on observations, interviews, and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to ensure an effective screening and onboarding system was developed and implemented to prevent 1(S12) of 1 unknown alleged agency staff from being assigned to provide direct resident to residents R1, R2, R3, R4, R5, R6, R7, R8, R9 and R10. This deficient practice had the potential to affect any of the 83 residents residing in the facility that received direct care from nursing personnel. An Immediate Jeopardy situation began on 03/12/2026 at 8:00 a.m. when S12, who was not employed by the facility or staffing agency, presented herself to S10LPN, S11LPN, and S13LPN stating she was a staffing agency CNA arriving to cover an open shift. Facility staff failed to ensure S12 was sent by the staffing agency, screened with credential verification, and onboarding was completed including orientation to the facility's policy and procedures, with abuse/neglect training prior to being assigned direct care of residents. From approximately 8:30 a.m. to 10:30 a.m. S12 was assigned to provide direct care to residents R1, R2, R3, R4, R5, R6, R7, R8, R9 and R10. Due to the facility's ineffective system for administrative staff to verify and approve agency personnel prior to assignment of resident care, residents R1, R2, R3, R4, R5, R6, R7, R8, R9 and R10 were placed at a likelihood of serious harm, injury, impairment, or death from occurring. S1ADM was notified of the Immediate Jeopardy on 03/13/2026 at 4:41 p.m.Findings:Cross Reference: F607 Review of the facility's revised policy dated 03/2025 and titled, Administration, Number 835 revealed, in part:Purpose: To administer the facility in such a way that residents are able to achieve their highest practicable level of functioning.Guidelines:1. Resources may include, but are not limited to, operating budget, staff, supplies or other services necessary to provide for the needs of residents.2. Facility administration may include the governing body, Management Company, and other identified by the facility as part of the facility administration, as well as the administrator. Review of the facility's Daily Assignment sheet dated 03/12/2026 revealed S12's name was handwritten and assigned to provide care to Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10. Review of Resident #R1's clinical record revealed he was admitted to the facility on [DATE] with a primary diagnosis Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Review of Resident #R2's clinical record revealed he was readmitted to the facility on [DATE] with a primary diagnosis Hemiplegia and Hemiparesis Following Other Cerebrovascular Disease Affecting Left Non-Dominant Side. Review of Resident #R3's clinical record revealed he was readmitted to the facility on [DATE] with a primary diagnosis Chronic Obstructive Pulmonary Disease with Acute Exacerbation. Review of Resident #R4's clinical record revealed he was readmitted to the facility on [DATE] with a primary diagnosis Gastrostomy Malfunction. Review of Resident #R5's clinical record revealed he was readmitted to the facility on [DATE] with a primary diagnosis Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side. Review of Resident #R6's clinical record revealed he was admitted to the facility on [DATE] with a primary diagnosis Unspecified Atrial Fibrillation. Review of Resident #R7's clinical record revealed she was readmitted to the facility on [DATE] with a primary diagnosis Non-Traumatic Subarachnoid Hemorrhage, Unspecified. Review of Resident #R8's clinical record revealed he was admitted to the facility on [DATE] with a primary diagnosis Hypertensive Urgency. Review of Resident #R9's clinical record revealed he was readmitted to the facility on [DATE] with a primary diagnosis Acute Infarction of Spinal Cord (Embolic) (Non-Embolic). Review of Resident #R10's clinical record revealed he was readmitted to the facility on [DATE] with a primary diagnosis Encephalopathy, Unspecified. An observation and interview was conducted on 03/12/2026 at 10:26 a.m. with S12. S12 was observed walking up to the main hallway near the gym and appeared very anxious, speaking very loudly, repeating I want to speak to the State, I know they are here. Surveyor identified self and S12 agreed to an interview. S12 stated she was not employed by the facility or a staffing agency. S12 then explained she entered the facility at 8:00 a.m. and inquired if there were any job openings. She said S14CNA then allowed her entry into the locked building and directed her to the nurses' station in the back of the facility to speak with S10LPN or S13LPN. S12 stated when she arrived to the nurse's station, S10LPN told her we need a CNA on the hall and asked her to change her shoes from flip flops to tennis shoes. S12 stated she then left the facility to change her footwear and returned within 5-10 minutes around 8:30 a.m. S12 stated S9R allowed reentry into the building. S12 said she then told S10LPN, S11LPN and S13LPN she was agency staff reporting for the open shift. S12 stated S11LPN gave her a temporary ID badge and assigned her to provide care to R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10. S12 stated she rounded, answered call lights, and went to the kitchen to obtain snacks for a couple of residents. S12 stated she answered the call light for Resident R4. S12 said she donned a gown and gloves because barrier precaution signage was posted outside the room, then entered the room and asked Resident R4 what he needed. S12 stated she then asked for S18CNA and S19CNA's assistance to help her after she touched Resident R4, rolled him over to remove his brief, and her gloved hand and gown sleeve became soiled with feces. S12 stated she then removed the soiled gloves and gown and left the room. S12 stated she became upset when S10LPN paged her, then approached S12 in the hallway, and asked where she had been. S12 stated she had then walked off the hall assignment, got a snack, and looked for the state surveyor. S12 stated S10LPN followed her down the hall and said You need to clock out. S12 then responded, I'm not clocked in. S12 confirmed S10LPN, S11LPN, and S13LPN were aware she had worked on the hall assignment, and at no point did any facility staff verify her identity or credentials prior to assigning resident care. Review of the facility's Visitor log sheet for 03/12/2026 revealed S12 was not listed. An interview was conducted with S13LPN on 03/13/2026 at 11:27 a.m. S13LPN confirmed she was part of the administrative staff at the facility. S13LPN verified S12 presented herself as agency staff today around 8:30 a.m. with S10LPN present. S13LPN verified S12 was not currently employed with the facility. S13LPN said S12 was asked if she was agency staff, and S12 responded yes. S13LPN stated she nor S10LPN verified if S12 was agency staff nor did they verify her credentials prior to S11LPN assigning S12 to the daily schedule to provide care for Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10. S13LPN confirmed the facility had no current process to pre-screen non-employees who enter the building or to provide onboarding orientation and competency evaluations of agency staff. S13LPN stated agency staff are expected to report to any hall, clock in through their agency on their cell phones, and look at the daily assignment sheet for their assigned residents. S13LPN stated agency staff do not receive facility orientation to review the facility's policy and procedures, abuse/neglect training, or complete a competency evaluation prior to assigning resident care. An interview was conducted with S11LPN on 03/12/2026 at 12:06 p.m. S11LPN verified she was approached by S12 this morning around 8:30 a.m. at the nurse's station, and S12 stated she was agency staff reporting for her shift. S11LPN stated she did not verify S12 was agency staff. S11LPN stated S12 did not have an agency ID badge, so she provided her a temporary ID badge and assigned her Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10. An interview was conducted with S10LPN on 03/12/2026 at 12:24 p.m. S10LPN confirmed she was part of the administrative staff at the facility. S10LPN verified S12 presented herself as agency staff today reporting for an assignment around 8:30 a.m. S10LPN confirmed the facility did not verify S12 to ensure she was agency staff. S10LPN said S11LPN assigned S12 to provide resident care to Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10. S10LPN stated the facility utilized agency staff often. S10LPN explained the process for obtaining agency staff would be for S25S to request staff for all open shifts with the staffing agency during the week, and then nursing administration on-call staff would request staff after-hours and on weekends/holidays. S10LPN stated all agency staff should be approved to work by either S25S or administrative staff, with verification of credentials confirmed. S10LPN stated the facility had no current process for completing agency staff's facility orientation, abuse/neglect training, or onboarding with competency verification prior to adding the agency staff to the facility's daily shift schedules. S10LPN confirmed S25S, S10LPN, nor any other administrative staff had verified S12 was agency staff, verified S12's credentials, or completed facility orientation or a competency evaluation prior to S12's assignment of resident care. An interview was conducted with S2DON on 03/12/2026 at 11:56 a.m. S2DON said S10LPN, S11LPN, and S13LPN reported S12 identified herself as agency staff reporting for duty around 8:30 a.m. S2DON stated S12 was then assigned to provide care to Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10. S2DON confirmed S12 was not employed by the facility or the staffing agency the facility utilized. S2DON stated the facility currently used agency staff often. S2DON confirmed the facility had no process in place to verify the identity of a non-employee upon entry into the facility, screened with credential verification, and onboarding was completed including orientation to the facility's policy and procedures, with abuse/neglect training prior to being assigned direct care of residents. S2DON verified S12 was allowed to care Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10 from 8:30 a.m. to approximately 10:30 a.m. An interview was conducted with S1ADM on 03/12/2026 at 4:15 p.m. S1ADM confirmed the facility had no process in place to verify the identity of non-employees upon entry into the facility and prior to assigning resident care. S1ADM confirmed S12 was not currently employed with the facility and had not been rehired or offered employment by the facility or the staffing agency the facility utilized as of 03/12/2026. S1ADM confirmed S12 should not have been allowed to provide care to residents residing in the facility. The Immediate Jeopardy was removed on 03/14/2026 at 4:59 p.m., after it was determined through observation, interview, and record review; that the facility implemented an acceptable Plan of Removal prior to the survey exit, which included: 1. Immediate Action Taken to Remove the Immediate JeopardyOn 03/12/2026, at approximately 10:25 a.m. the facility became aware that an individual presented herself as agency nursing staff and entered the facility without verification of employment or credentials. Immediate action was taken to ensure the individual was no longer present in the facility and to ensure that only verified nursing staff were permitted to provide resident care. On 03/12/2026, the management team conducted an immediate search of the facility to locate the individual and confirmed she was no longer present in the building. The facility verified with the staffing agency that the individual was not employed by the agency and confirmed through the facility staffing system that she was not an active employee of the facility, as she had previously been terminated in December 2025.The individual, S12, is listed as a Certified Nursing Assistant in the State of Louisiana with certification dated 07/15/2025. She was not employed by the facility or the staffing agency at the time of the incident. The facility immediately ensured that S12 was not permitted to provide resident care and confirmed she was no longer present in the building.The Police Department was contacted by the Administrator and responded to the facility at approximately 5:15p.m., to document the incident and obtain identifying information related to the individual.Additionally, the facility implemented an immediate 24-hour monitoring of the front entrance at approximately 4:45p.m., to ensure that all individuals entering the building are identified, verified, and logged in before entering.These actions immediately removed the potential for the unidentified individual to access residents or provide resident care. 2. Identification of Residents Who Were Potentially AffectedResidents who could have potentially been affected were immediately evaluated.Residents assigned to the unit where S12's name had been placed on the assignment sheet were interviewed by the DON on 03/12/2026 at approximately 12:00 p.m. to determine whether she provided care or performed any nursing assistant duties. Residents reported that she had not provided care.To ensure the protection of all residents in the facility:On 03/14/2026, all residents with a BIMS score of 8 or greater were interviewed regarding any concerns related to care provided by unknown staff.Residents with a BIMS score of less than 8 received a head-to-toe assessment to evaluate any signs of injury, neglect, abuse, or improper care.All interviews and assessments will be completed by 6:00 p.m. on 03/14/2026.No findings of injury, neglect, abuse, or inappropriate care were identified.The facility's immediate investigation, resident interviews, assessments, staffing verification review, and follow-up monitoring found no evidence that S12 provided resident care, performed resident services, or caused actual resident harm during the specified time period. 3. Systemic Corrective Actions ImplementedThe facility implemented the following systemic corrective actions to ensure that only qualified and verified nursing staff provide resident care:On 3/13/2026, at 4:45 p.m., a trained facility staff member 24-hour monitor was implemented to verify all individuals entering the facility.All staff and visitors entering the building are now required to sign in and out at the front desk.The front desk is monitored continuously to ensure the entry process is followed and that unknown individuals are not allowed entry.Keypad door codes were changed throughout the facility: Starting 03/12/2026 at 4:00 p.m. and completed on 03/13/2026 to prevent unauthorized access. All previously stored codes were deleted, and new codes were input.Additionally, education for all staff in all departments began on 03/13/2026 by the Staff Development Coordinator (SDC) at approximately 5:00 p.m. regarding:Verification of agency staff with verification of licensing boards and registries will be completed by the scheduler and or the Payroll Benefits coordinator (PBC) and maintained on file with the facility prior to being placed on the daily schedule. During weekends and/ or holidays it will be performed by the DON.The facility will verify abuse training requirements are met by obtaining a copy of the training from the agency and providing the abuse training at the beginning of their first scheduled shift with the facility.Staff responsibility to report unknown individuals attempting to provide resident care immediately to the DON or Administrator after ensuring the resident's safety.Facility entry procedures and sign-in requirements.Abuse prevention and resident safety.Education will be completed for all staff by 03/16/2026 at 11:00 p.m., and staff who were not present during the initial education will receive education prior to their next scheduled shift.Education and training will be completed by the Chief Nursing Officer (CNO) with the Regional Director of Clinical (RDC), administrator, DON, ADONs, SDC, and administrative staff on3/14/2026.The RDC and/or regional and corporate staff, through onsite visits, will monitor the administrative staff for compliance, verifying that all agency staff have been verified and trained on abuse, and the facility requires all staff and visitors entering the building to sign in and out at the front desk. In addition to verifying, the front desk is monitored continuously to ensure the entry process is followed and that unknown individuals are not allowed entry. This will be monitored weekly for 4 weeks then monthly for 3 months. Regulatory Compliance Statement (F835 Alignment)The facility implemented immediate corrective actions to ensure compliance with 42 CFR 9483.35 Nursing Services, which requires the facility to provide sufficient numbers of nursing staff with the appropriate competencies and skill sets to assure resident safety and meet resident needs.Effective immediately, only nursing staff whose employment status, credentials, and agency authorization have been verified by facility leadership prior to assignment will be permitted to provide resident care.These measures ensure that only qualified, trained, and verified nursing personnel are assigned to residents, thereby protecting residents from the potential risk of serious injury, serious harm, serious impairment, or death. 4. Monitoring to Ensure Ongoing ComplianceThe facility will monitor compliance with these corrective actions to ensure ongoing resident safety and regulatory compliance.The Administrator and Director of Nursing will review the entry sign-in log daily x 12 weeks and ongoing to ensure all staff entering the facility are verified.The administrator, DON, ADON, and SDC will conduct random audits of staffing assignments daily x 4 weeks, 3xweek x 4 weeks, weekly x 4 weeks and ongoing to confirm that only verified employees or agency staff provide resident care.Verification of agency staff credentials and agency confirmation [NAME] be completed prior to assigning any agency staff to provide resident care by the Scheduler/Payroll Benefits Coordinator. The facility asserts that the likelihood of serious injury, serious harm, serious impairment, or death to residents no longer exists as of 3/14/2026. The deficient practice continued at a potential for more than minimal harm for the 83 residents residing in the facility.

Based on observations, interviews and record review the facility failed to ensure an effective system was in place for staff to identify residents assessed as unsafe smokers and to provide supervision and interventions during smoking for 1 (#50) of 3 residents reviewed for smoking. Review of the facility's policy, Physical Environment- Facility with Independent and Supervised Smokers, revised 03/2025, revealed the following in part:Purpose: To provide a safe environment for residents.Guidelines:Smoking blankets or aprons will be furnished for residents who are assessed to require a smoking blanket or apron.Residents who are independent smokers are instructed not to share smoking paraphernalia with other residents or staff.Residents who are deemed unsafe to smoke independently will be supervised by staff members while smoking.Review of Resident #50's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included the following: Cerebral Infarction due to Embolism of Left Middle Cerebral Artery, Aphasia following Cerebral Infarction, Dysphagia following Cerebral Infarction, and Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side. Review of Resident #50's Quarterly MDS with an ARD of 11/04/2025 revealed Resident #50 was assessed by the facility to have a BIMS of 6, which indicated the resident was severely cognitively impaired. Further review revealed he self-propelled himself independently in his wheelchair.Review of Resident #50's Clinical Record revealed, in part, the following practitioner note dated 05/05/2025:Seen today per staff request. Patient burned his clothing with cigarette. He did not burn his skin. ExaminationConstitutional: No apparent distress. Alert and oriented times 2. Delayed speech. Limited ability to communicate.Musculoskeletal: Right hemiparesisNeurological: Right upper extremity paralysis, Right lower extremity weakness, delayed speechReview of Resident #50's current Care Plan revealed the following, in part: Focus: The resident is a smoker. Interventions:The resident requires a smoking apron while smoking. Date Initiated: 05/07/2025.The resident requires supervision while smoking. Date Initiated: 05/07/2025. Review of Resident #50's Smoking Screen, dated 08/18/2025, revealed the following, in part:Does the resident smoke? Yes.How many times does the resident smoke per day? 2-5 timesThe resident has cognitive loss. Yes. The resident has a history of hiding their smoking materials or activities from the staff. Yes.The resident has a history of noncompliance with the facilities smoking policy. Yes. The resident has a history of smoking in non-designated smoking areas. Yes. The resident is unable to use a fire extinguisher to extinguish a fire as a result of smoking. Yes. The resident uses medications that could cause drowsiness. Yes.Can the resident light his/her own cigarette/activate electronic cigarette? No.Adaptive equipment needed: The resident requires a smoking apron while smoking.Interventions and Determinations: The resident requires SUPERVISION while smoking.Review of Resident #50's Smoking Screen, dated 11/18/2025, revealed the following, in part: Does the resident smoke? Yes.How many times does the resident smoke per day? 5-10 times.The resident has cognitive loss. Yes.The resident has dexterity problem(s). Yes.The resident has a history of hiding their smoking materials or activities from the staff. Yes.The resident has a history of noncompliance with the facilities smoking policy. Yes. The resident has a history of smoking in non-designated smoking areas. Yes. The resident is unable to retrieve a cigarette if it were dropped. Yes. The resident is unable to use a fire extinguisher to extinguish a fire as a result of smoking. Yes.On 12/09/2025 at 11:17 a.m., an observation was made of Resident #50 seated in his wheelchair in the facility's designated smoking area. Resident #50 was observed leaning forward with his upper body noticeably tilted to the right side of the wheelchair. Resident #50 held a partially smoked cigarette in his left hand. Resident #50 propelled his wheelchair with his feet toward another resident, who then lit Resident #50's cigarette. After the cigarette was lit, Resident #50 was observed loosely holding the lit cigarette in his left hand. Resident #50 was not observed wearing a smoking apron and no staff member was present to supervise the resident while he was smoking.On 12/09/2025 at 11:20 a.m., an interview was attempted with Resident #50. Resident #50 did not hold eye contact or make verbal responses. Resident #50 vocalized a sound. Due to Resident #50's inability to communicate the interview was discontinued. On 12/09/2025 at 11:25 a.m., an interview was conducted with S5ADON. S5ADON confirmed Resident #50 was currently in the smoking area and not being supervised by facility staff and was not wearing a smoking apron. S5ADON stated Resident #50 was not a smoker. S5ADON stated there was no designated staff member assigned to supervise unsafe smokers, but S11AC could see the smoking area from the activity room. On 12/09/2025 at 11:27 a.m., an interview was conducted with S11AC. S11AC stated she was not responsible for the supervision of the designated smoking area and was unaware of what residents needed supervision while smoking. On 12/09/2025 at 11:46 a.m., an interview was conducted with S12LPN. S12LPN stated Resident #50 resided on Hall A and she was assigned to care for the resident. S12LPN did not know if Resident #50 was an unsafe smoker that required supervision while smoking and a smoking apron. S12LPN stated if Resident #50 required supervision she would periodically go to the designated smoking area to check on him, but was not sure when the last time this happened. S12LPN stated there was not a list of unsafe smokers requiring supervision on Hall A. S12LPN stated there was no designated smoking times and any resident can smoke at any time. S12LPN confirmed Resident #50 was care planned to need a smoking apron and supervision while smoking.On 12/09/2025 at 12:14 p.m., an interview was conducted with S8CNA. S8CNA stated she did not know Resident #50 was an unsafe smoker that required supervision while smoking and a smoking apron. S8CNA stated she did not know where to find if a resident was considered a safe or unsafe smoker or any smoking interventions. S8CNA stated she had seen Resident #50 smoke shortly before Thanksgiving. S8CNA stated she did not know if there were any other residents in her assignment needing a smoking apron or staff supervision while smoking. S8CNA stated there was no list on Hall A that indicated who was unsafe or safe to smoke.On 12/09/2025 at 12:26 p.m., an observation was conducted of the Hall B nurse station with S15LPN. S15LPN retrieved a smoker list from a binder behind the desk. S15LPN stated the list only contained residents for Hall B. S15LPN stated the list did not indicate whether each smoker on the list was deemed safe or unsafe, only that the resident smoked.On 12/09/2025 at 12:30 p.m., an interview was conducted with S21CNA. S21CNA stated the facility did not have designated smoking times and residents could go outside to the courtyard to smoke whenever they like. S21CNA stated she did not know how to identify which residents required supervision or a smoking apron and did not know who was responsible to supervise unsafe smokers. S21CNA demonstrated the view of the electronic chart for her assigned residents. She was unable to locate whether a resident was unsafe or safe to smoke in the electronic chart.On 12/09/2025 at 12:35 p.m., an interview was conducted with S20LPN. She stated the facility did not have designated smoking times and residents could go outside to the courtyard to smoke whenever they wanted to. She stated she did not know how to identify which residents required supervision or a smoking apron and did not know who was responsible to supervise unsafe smokers. S20LPN stated she was familiar with Resident #50 and did not know the resident was an unsafe smoker who required supervision while smoking and a smoking apron.On 12/09/2025 at 12:40 p.m., an interview was conducted with S19CNA. She stated the facility did not have designated smoking times and residents could go outside to the courtyard to smoke whenever they would like to. She stated she did not know how to identify which residents required supervision or a smoking apron and did not know who was responsible to supervise unsafe smokers. S19CNA demonstrated she was unable to locate whether a resident was unsafe or safe to smoke in the electronic chart. S19CNA stated she had cared for Resident #50 and did not know the resident was an unsafe smoker who required supervision while smoking and a smoking apron.On 12/09/2025 at 12:40 p.m., an interview was conducted with S15LPN. She stated the facility did not have designated smoking times and residents could go outside to the courtyard to smoke whenever they would like to. She stated she did not know how to identify which residents required supervision or a smoking apron and did not know who was responsible to supervise unsafe smokers. S15LPN stated she was familiar with Resident #50 and did not know the resident was an unsafe smoker who required supervision while smoking and a smoking apron.On 12/09/2025 at 12:45 p.m., an interview was conducted with S14LPN. She stated the facility did not have designated smoking times and residents could go outside to the courtyard to smoke whenever they wanted to. She stated she did not know how to identify which residents required supervision or a smoking apron and did not know who was responsible to supervise unsafe smokers. S14LPN stated she was familiar with Resident #50 and did not know the resident was an unsafe smoker who required supervision while smoking and a smoking apron.On 12/09/2025 at 12:50 p.m., an interview was conducted with S18CNA. She stated the facility did not have designated smoking times and residents could go outside to the courtyard to smoke whenever they would like to. She stated she did not know how to identify which residents required supervision or a smoking apron and did not know who was responsible to supervise unsafe smokers. S18CNA stated she had cared for Resident #50 and did not know the resident was an unsafe smoker who required supervision while smoking and a smoking apron.On 12/10/2025 at 2:03 p.m., an interview was conducted with S25NP. S25NP stated she provided care for Resident #50. S25NP stated Resident #50 had a Cerebral Infarction and suffered from right sided extremity impairment, muscle weakness, and communication deficits. S25NP stated if Resident #50 was assessed to require a smoking apron and staff supervision during smoking, she expected the facility to provide that care at all times. On 12/09/2025 at 1:27 p.m., an interview was conducted with S2DON. S2DON stated every resident was assessed for smoking upon admission to the facility. She stated the assessment was completed by the nurse receiving the resident. She stated if the nurse selected the resident was not a smoker, then the assessment was complete. She stated if the nurse selected the resident was a smoker, then more questions populated in regards to cognition, mobility/dexterity, medications, and needed interventions. She stated the assessment did not score a resident but, rather, the nurse completing the assessment had to unselect any interventions the nurse deemed not needed. S2DON stated the electronic health record system then automatically created the smoking care plan based upon the nurse's smoking assessment. She stated a smoking assessment populated for completion in the electronic health record upon admit, readmit, quarterly, annually, and could be triggered as needed due to any incident. S2DON stated a nurse should know a resident's smoking status and interventions by reviewing the resident's care plan. She further stated there should be a smoker list at each of the facility's two nurses' stations; however, she confirmed those lists did not indicate a resident's safe smoking status or required interventions and CNAs did not have access to those lists. S2DON stated a CNA should know a resident's smoking status and interventions by reviewing the electronic chart. She stated smoking status and required interventions to be communicated from shift to shift through nurse-to-nurse and CNA-to-CNA report. S2DON stated there was no staff designated to supervising unsafe smokers. She stated the designated smoking area was an open courtyard accessible to any resident. She confirmed there was no designated smoking times for residents. S2DON reviewed Resident #50's care plan and confirmed Resident #50 required the use of a smoking apron and staff supervision while smoking. S2DON stated Resident #50 was the only smoker in the facility that required a smoking apron or supervision while smoking. On 12/10/2025 at 2:00 p.m., an interview conducted with S1ADM revealed the facility identified five additional unsafe smokers since yesterday that required supervision/smoking apron through their facility wide assessment. S1ADM stated Resident #50 was assessed and a new smoking evaluation completed. He stated the facility completed a new facility wide smoking assessment on all residents, a new position of a safe smoking monitor was added to daily staffing to supervise the smokers, smoking binders were implemented to assist staff in identifying smokers, residents identified as smokers signed agreements that included expectations of safe smoking, and a resident council meeting was conducted to announce the smoking times and process on 12/10/2025. S1ADM explained the smoking binder would include resident's smoking supervision status and interventions. He stated facility leadership began educating staff on the role expectations of the smoking monitor, the new smoking binders, and the smoking policy on 12/09/2025.

Based on observations, interviews, and policy review, the facility failed to store food under sanitary conditions by failing to ensure food was properly dated, labeled, and sealed in the walk-in refrigerator and freezer. This deficient practice had the potential to affect 72 residents who ate from the facility's kitchen.Findings: Review of the facility's policy dated 03/2023 and titled, Food Safety, revealed the following, in part:9. Refrigerated foods:f. Food, including leftovers, will be labeled and dated in the refrigerator. On 12/08/2025 at 8:14 a.m., an initial tour was conducted of the facility's kitchen with S4CK. The following observations were made with S4CK: Walk-in refrigerator:1 metal pan of mustard greens covered with plastic wrap with no date or label; and 3 pork loins with no date or label. Walk-in freezer: 1 metal pan of green beans with no date or label; 1 clear bag of hamburger patties, not sealed, open to air, with no open date. On 12/08/2025 at 8:22 a.m., an interview was conducted with S4CK. She confirmed the above observations. S4CK confirmed the refrigerator and freezer items should have been labeled, dated, and sealed and were not. On 12/08/2025 at 8:37 a.m., an interview was conducted with S3DM. She was informed of the above observations. S3DM confirmed all foods should have been sealed, dated, and labeled. S3DM confirmed 72 residents ate out of the kitchen. On 12/09/2025 at 12:16 p.m., an interview was conducted with S1ADM. He was notified of the above observations of the facility's refrigerator and freezer. S1ADM confirmed all foods should have been labeled, sealed, and dated.

Based on observations and interviews, the facility failed to ensure the residents had a safe, clean, comfortable homelike environment by failing to maintain a clean environment 1 (#74) of 24 sampled residents. Findings: Review of Resident #74's clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #74's MDS with an ARD of 11/11/2025 revealed the facility assessed him to have a BIMS of 15, which indicated he was cognitively intact. On 12/08/2025 at 9:05 a.m., an interview was conducted with Resident #74. Resident #74 stated his toilet was clogged with feces and toilet paper. He stated it had been clogged for at least 3 days. Resident #74 stated he could not use the toilet in his room and had to use a restroom at the end of his hall. He stated he reported the clogged toilet to a CNA 2 days ago and nothing had been done. On 12/08/2025 at 9:10 a.m., an observation was conducted of Resident #74's restroom. The toilet was observed with multiple layers of feces and toilet paper. The feces in the toilet was dry with very little water in the bottom of the bowl. On 12/08/2025 at 3:25 p.m., an observation was conducted of Resident #74's toilet, it remained clogged with multiple piles of feces and toilet paper. On 12/09/2025 at 9:30 a.m., an interview was conducted with S6HKS. S6HKS stated she was made aware of the clogged toilet on 12/08/2025 at 3:40 p.m. S6HKS stated housekeeping staff is responsible for cleaning each room daily. S6HKS stated each resident's entire bathroom should be cleaned once a day and as needed. S6HKS stated at 7:00 a.m. daily rounds are completed in each resident room, including restroom. S6HKS stated she expected the issue to be discovered when daily rounds were completed or when housekeeping staff was cleaning the bathroom and it was not. On 12/09/2025 at 11:00 a.m., an interview was conducted with S1ADM. S1ADM stated he would expect housekeeping staff to identity a clogged toilet on their daily rounds, and report it to maintenance and they did not.

Based on record review and interview, the facility failed to ensure residents with an identified mental health diagnosis were referred for a Pre-admission Screening and Resident Review (PASARR) Level II evaluation as required for 1 of 1 (#12) resident reviewed for PASARR.Review of Resident #12's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Hemiplegia and Hemiparesis. Further review revealed an additional medical diagnosis of Unspecified Psychosis with an onset date of 09/30/2019.Review of Resident #12's PASARR Level I dated 09/27/2019 revealed no mental health diagnoses were selected. Further review revealed no review for a Level II evaluation and determination had been submitted for Resident #12 to include his diagnosis of Unspecified Psychosis.An interview was conducted on 12/09/2025 at 2:30 p.m. with S9SS. She reviewed Resident #12's PASARR pre-admission Level I and resident review dated 09/27/2019. She confirmed Resident #12 had a diagnosis of Unspecified Psychosis upon admission and was not accurately screened. She confirmed Resident #12 should have had a new resident review conducted but did not.An interview was conducted on 12/10/2025 at 4:00 p.m. with S2DON. She reviewed Resident #12's PASARR pre-admission Level I and resident review dated 09/27/2019. She confirmed Resident #12 had a diagnosis of Unspecified Psychosis upon admission.

Based on observations, interviews, and record review, the facility failed to ensure interventions for smoking were implemented as identified on the care plan for 1 (#50) of 3 residents reviewed for smoking.Review of the facility's policy, Physical Environment- Facility with Independent and Supervised Smokers, revised 03/2025, revealed the following in part:Purpose: To provide a safe environment for residents.Guidelines:Smoking blankets or aprons will be furnished for residents who are assessed to require a smoking blanket or apron.Residents who are deemed unsafe to smoke independently will be supervised by staff members while smoking. Review of Resident #50's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included the following: Cerebral Infarction due to Embolism of Left Middle Cerebral Artery, Aphasia following Cerebral Infarction, Dysphagia following Cerebral Infarction, and Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side. Review of Resident #50's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/04/2025 revealed Resident #50 was assessed by the facility to have a Brief Interview Mental Status (BIMS) of 6, which indicated the resident was severely cognitively impaired.Review of Resident #50's current Care Plan revealed the following, in part: Focus: The resident is a smoker.Interventions:The resident requires a smoking apron while smoking.The resident requires supervision while smoking.On 12/09/2025 at 11:17 a.m., an observation was made of Resident #50 smoking in the designated smoking area without supervision or a smoking apron.On 12/09/2025 at 11:25 a.m., an interview was conducted with S5ADON. S5ADON confirmed Resident #50 was in the smoking area and not being supervised by facility staff and was not wearing a smoking apron. On 12/09/2025 at 11:46 a.m., an interview was conducted with S12LPN. S12LPN stated she was unaware Resident #50 was outside smoking. S12LPN stated she had not yet reviewed Resident #50's care plan this shift. S12LPN did not recall if Resident #50 needed supervision or a smoking apron.On 12/09/2025 at 12:14 p.m. an interview was conducted with S8CNA. S8CNA stated she was unaware Resident #50 was outside smoking. S8CNA stated she was unaware if Resident #50 was an unsafe smoker. S8CNA stated she was unaware of where to find smoking interventions for Resident #50.On 12/09/2025 at 1:27 p.m., an interview was conducted with S2DON. S2DON stated she expected all nursing staff to implement the interventions stated on residents' care plans. S2DON reviewed Resident #50's care plan and confirmed Resident #50 required the use of a smoking apron and staff supervision while smoking. S2DON further confirmed Resident #50's care plan interventions were not implemented while smoking and should have been.

Based on record review, observation and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 1 (#2) of 3 resident's observed for perineal care. The facility failed to ensure staff performed hand hygiene and proper glove use for Resident #2 during perineal care.Review of the facility's policy titled, Perineal Care with a revision date of 03/2025, revealed the following, in part:Policy: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote: cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Policy explanation and compliance guideline: 6.) Perform hand hygiene and put on gloves.10.). Change gloves if soiled and continue with perineal care. Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of Personal History of Urinary Tract Infections with Gram-Negative Sepsis and Irritable Bowel Syndrome. Review of the facility's Infection Log revealed Resident #2 was treated for a Urinary Tract Infection with Sepsis on 10/06/2025. 0n 12/09/2025 at 12:00p.m., an observation was made of S8CNA performing peri care for Resident #2. S8CNA failed to perform hand hygiene prior to donning a clean pair of gloves. Resident #2 was observed to be soiled of urine and feces. S8CNA removed and disposed of the soiled adult brief. S8CNA failed to remove the soiled gloves and perform proper hand hygiene. S8CNA then continued to apply a clean adult brief, and adjust Resident #2's bed linen.S8CNA handed Resident #2 the call light and television remote before removing the soiled gloves. S8CNA removed soiled gloves without performing hand hygiene prior to exiting Resident #2's room. On 12/09/2025 at 12:18p.m., an interview was conducted with S8CNA. S8CNA stated she was unaware she should change gloves and perform hand hygiene during the dirty to clean peri care transition process. S8CNA confirmed she did not change gloves or perform hand hygiene before entering and prior to exiting Resident #2's room. 0n 12/10/2025 at 10:25a.m., an interview was conducted with S7ICN. S7ICN confirmed proper hand hygiene should be performed prior to direct contact with residents as well as between dirty to clean process of peri care. S7ICN stated after proper handwashing she would expect staff to don a clean pair of gloves before proceeding with direct care. On 12/10/2025 at 10:35a.m., an interview was conducted with S2DON. S2DON confirmed proper hand hygiene should be performed prior to direct contact with residents as well as between dirty to clean process of peri care. S2DON stated after proper handwashing she would expect staff to don a clean pair of gloves before proceeding with direct care.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care for 1 (#46) of 18 residents observed for ADL's in the final sample. Findings: Review of the policy titled, Quality of Life, Activities of Daily Living /Maintain Abilities dated 03/2023 revealed the following: Purpose: Facility provides necessary care and services to support the resident's needs and choices. Guidelines: 1. A resident is given appropriate treatment and services to maintain or improve his/her ability to carry out the activities of daily living, including those specified below: a. Hygiene-bathing, grooming, dressing and oral care 2. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Review of the clinical record for Resident #46 revealed he was admitted to the facility on [DATE] with diagnoses, which included Disorder of the Autonomic Nervous System and Unspecified Lack of Coordination. Review of Resident #46's Quarterly MDS with an ARD of 05/07/2025 revealed he had a BIMS of 9, which indicated moderate cognitive impairment. Further review revealed Resident #46 was Dependent and required assistance from staff for personal hygiene needs. Review of Resident 46's Care Plan revealed the following: Focus: Requires assistance with ADL's r/t hx of motorcycle accident, neuralgia, need for geri-chair for mobility Intervention: The resident is dependent on staff for personal hygiene and oral care. On 06/30/2025 at 8:45 a.m., an observation was made of Resident #46's fingernails. Resident #46's fingernails were observed to be long, yellow in discoloration with dirt and grime embedded underneath nail. On 07/01/2025 at 9:45 a.m., an interview was conducted with Resident #46. He stated he had been asking to have his finger nails trimmed for over a month. He stated having long finger nails sucked and wanted them trimmed. An additional observation was made of Resident #46's nails remained long, yellow in discoloration with dirt and grime embedded underneath nail. He stated he was dependent on staff to assist him with trimming his nails. On 07/02/2025 at 2:53 p.m., an interview was conducted with S5CNA. S5CNA stated he had observed Resident #46's fingernails being long, unclean, and needed to be trimmed 3- 4 days ago. S5CNA denied assisting Resident #46 with nail cleaning and trimming or reporting this observation to anyone. S5CNA confirmed Resident #46 was dependent and required assistance for maintaining personal hygiene needs. On 07/02/2025 at 3:29 p.m., an observation and interview was conducted with S1IPRN. She described Resident #46's fingernails as being long, yellow in discoloration with dirt and grime underneath nail and in need of being trimmed immediately. She confirmed Resident #46 was dependent on staff to meet his personal hygiene and grooming needs. On 07/02/2025 at 3:30 p.m., an observation and interview was conducted with S2DON. She described Resident #46's fingernails as being long, yellow in discoloration with dirt and grime underneath nail and in need of being trimmed. She confirmed Resident #46 was dependent on staff to meet his personal hygiene and grooming needs. She stated nursing aides, floor nurse or treatment nurse assisted with maintaining nail care needs for residents. She stated she would expect staff to have identified Resident #46 need for nail care and provide assistance with cleaning and trimming nails and did not.

Based on observation, interviews, and record review, the facility failed to honor and accommodate resident food allergies, intolerances, and preferences by failing to ensure a resident received meals that did not include food allergies for 1 (#63) of 2 (#31 and #63) residents reviewed for dietary services. This deficient practice had the potential to affect all residents who consumed meals from the kitchen. Findings: Review of Resident #63's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #63's Allergies in the electronic health record revealed the following: Allergies: Iodine from food, Shellfish derived product Review of Resident #63's current Care Plan revealed the following, in part: Focus: Resident #63 is allergic to iodine from food, shellfish derived products Interventions: Benadryl as ordered for potential allergic reaction, label medical record with allergy, and notify pharmacy and dietary of allergies. Review of Resident #63's June 2025 Medication Administration Record revealed on 06/29/2025 the resident was administered two 25 mg tablets of Diphenhydramine HCL for allergy related symptoms. Review of Resident #63's Departmental Progress Note dated 06/29/2025 revealed the following, in part: Incident: Resident #63 came out from room and reported being served crab cake despite having a known shellfish allergy. Resident complained of facial tingling and tongue swelling. Interventions: Nurse practitioner was notified and ordered Diphenhydramine 50 mg, administered per order. Resident was monitored closely following administration. Actions taken: Lunch tray was immediately removed. Resident was served a different meal that did not contain shellfish. Dinner tray was double-checked prior to serving to ensure no allergens were present. Outcome: Patient reported no further symptoms. Swelling and tingling resolved. Condition stable. Review of Resident #63's Meal Ticket dated 07/01/2025 revealed the following, in part: Allergies: Shellfish Review of the menu provided by the facility revealed crab cakes were served for lunch on 06/29/2025. On 07/01/2025 at 10:00 a.m., an interview was conducted with Resident #63. He stated on 06/29/2025 he was served crab cakes for lunch. He stated he has an iodine and shellfish allergy that the facility is aware of. On 07/01/2025 at 1:35 p.m., an interview was conducted with S3DM. She stated the dietary staff were aware of Resident #63's allergy to shellfish and iodine as it is listed on all his tickets and in his chart. She reviewed Resident #63's meal ticket dated 07/01/2025 and confirmed it listed shellfish as an allergy. She confirmed on 06/29/2025 Resident #63 was mistakenly served crab cakes for lunch. She confirmed Resident #63 was served crab cakes and should not have been served it as he had an allergy to shellfish. She confirmed a resident who was allergic to shellfish and whose meal ticket listed shellfish as their allergy should not have been served crab cakes. On 07/01/2025 at 2:21 p.m., a telephone interview was conducted with S4LPN. She stated she worked on Sunday 06/29/2025 and was the nurse assigned to Resident #63. She confirmed Resident #63 had an allergy to shellfish and was served crab cakes for lunch on 06/29/2025 and should not have been. On 07/02/2025 at 3:05 p.m., an interview was conducted with S2DON. She confirmed a resident who was allergic to shellfish and whose meal ticket listed shellfish as an allergy should not have been served crab cakes. She confirmed residents should not be served any foods they are allergic to.

Based on observations, interviews and record reviews, the facility failed to provide appropriate treatment and services for 1 (#1) of 3 (#1, #2, and #3) newly admitted or readmitted residents who needed physician orders for immediate care and/or follow up for surgery and for implanted devices. For 26 days, the facility failed to ensure the Admission Nurse, Charge Nurses, Wound Care Nurses, Licensed Practical Nurses and Registered Nurses: 1. Had accurately transcribed and clarified Resident #1's 01/24/2025 hospital discharge recommendations, wound care and dressing orders, cardiology follow up for surgical incision care, and monitoring equipment instructions; 2. Understood and acted as needed on their responsibilities for Resident #1's cardiac loop recorder and; 3. Assessed, monitored, documented, and treated Resident #1's surgical incision site, loop recorder, and loop recorder monitoring equipment. This deficient practice resulted in an Immediate Jeopardy situation on 01/24/2025, when Resident #1 was readmitted to the facility from the hospital after a surgical implantation of a loop recorder with monitoring equipment. Facility staff failed to accurately transcribe and clarify the resident's discharge orders and complete accurate skin assessments which resulted in Resident #1 not receiving care and treatment for the newly acquired surgical incision site or staff assistance with ensuring the monitoring equipment was functioning from 01/24/2025 through 02/20/2025. This deficient practice created a likelihood Resident #1 would suffer from post-surgical incision site complications and delayed treatment of an arrhythmia identified from the loop recording. S1ADM was notified of the Immediate Jeopardy on 02/20/2025 at 6:32 p.m. The Immediate Jeopardy was removed on 02/21/2025 at 6:45 p.m., as confirmed by onsite verification through record reviews and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. This deficient practice continued at the potential for more than minimal harm for all 86 residents residing in the facility. Findings: 1. and 2. Review of the manufacture's information and guidelines dated 08/2024 revealed the following information regarding a loop recorder, in part: The Insertable Cardiac Monitor (ICM) is implanted in patient left chest wall under the skin and records subcutaneous Electrocardiogram (ECG) data. The ICM is indicated in patients with a diagnosis of cryptogenic stroke. The ICM works continuously to capture comprehensive and actionable ECG data for up to three years. The ICM automatically-activated monitoring system included ECG data transmission from the ICM, through the patient's monitor, to the cloud network, and then made available to the doctor. The network sends alerts to the doctor of abnormal ECG data. Potential adverse events or potential complications of ICM devices include, but are not limited to, device rejection phenomena (including local tissue reaction), device migration, infection, and erosion through the skin. Review of the facility's policy titled Resident Assessments Admission Physician Order for Immediate Care dated 03/2023 revealed the following in part: Purpose: To provide each resident with necessary care and services upon admission. Policy: The facility will have physician orders for the resident's immediate care, at the time of admission. Guidelines: 1. Physician orders for immediate care may be written or verbal. 2. These orders will enable facility staff to provide essential care to the newly admitted resident 3. These orders will be consistent with the resident's physical status. 5. These orders will be in place to facilitate care for the resident until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. Review of Resident #1's Clinical Records revealed he was readmitted to the facility from the hospital on 01/24/2025 with diagnoses, which included Acute Arterial Ischemic Stroke, Multifocal, and Multiple Vascular Territories. Review of Resident #1's local hospital records dated 01/19/2025 through 01/24/2025 revealed Resident #1's hospital cardiologist implanted a loop recorder on 01/24/2025. Further review revealed the hospital cardiologist MD and NP documented the following, in part: 01/24/2025 Recommend loop recorder implantation for determination of paroxysmal atrial fibrillation or atrial arrhythmias with Cryptogenic Stroke diagnosis. Recommend outpatient follow-up for wound check in 1 week for a nurse visit and follow-up with cardiology evaluation in about 4 weeks' time. Wound care instructions: May remove outer large clear adhesive in 48 hrs. Encouraged to maintain the white adhesive strip in place until follow-up visit in the office. Do not remove the white adhesive strip. Patient may shower in 24 hours. Apply soap and dab the area dry at insertion site. Encouraged patient to return if this has any discharge or drainage from the incision or if any erythema, fevers or chills noted. Review of Resident #1's After Visit Summary Discharge Instructions Orders (AVS) for Local Hospital admitted d 01/19/2025 through 01/24/2025 revealed discharge instructions for loop recorder: You may shower in 24 hours after the procedure. Allow soapy water to gently run over chest incision, not directly on incision. Do not rub or scrub incision. No bathtubs or submerging in water until site is completely healed. Keep site clean and dry at all times. Inspect site daily for tenderness, discharge, or signs of infection. Apply ice pack for 24 hours. Do not remove the white adhesive strip, allow them to fall off on their own. Further review revealed no cardiologist follow up with the local hospital cardiologist who implanted the loop recorder. Review of Resident #1's hospital cardiologist letter dated 2/21/2025 revealed Resident #1 had loop recorder equipment with instructions to be plugged up beside Resident #1's bed and if power flashes please unplug and plug back in after 5 minutes. Review of Resident #1's Physician Orders from 10/31/2024 through 02/18/2025 revealed no physician's orders addressing Resident #1's surgical incision, cardiology follow up appointment, loop recorder monitoring, or equipment. Review of Resident #1's current Care Plan revealed no evidence a care plan was developed with interventions implemented for a surgical incision to the left chest wall or the loop recorder equipment. Review of Resident #1's Nursing Notes from 01/01/2025 through 02/18/2025 revealed no evidence of Resident #1's surgical incision site, cardiology follow up appointments, or the loop recorder were addressed by staff. Review of Resident #1's Nurse Practitioner Progress notes from 01/01/2025 through 02/18/2025 revealed on 01/25/2025 at 5:40 p.m., S6NP documented loop recorder was placed while inpatient. Resident #1 is discharged to the facility for continued long term care and will follow up with cardiology as scheduled. Staff to request discharge summary. Follow up with cardiology as scheduled. Review of Resident #1's Medication Administration Record and Treatment Administration Record from 01/24/2025 to 02/18/2025, 26 days, revealed no surgical incision site care or the loop recorder equipment monitoring. Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/30/2025 revealed he had a Brief Interview for Mental Status (BIMS) of 15, which indicated cognitively intact. Further review revealed Resident #1 was not coded as having a surgical incision. An observation was made and interview conducted with Resident #1 on 02/17/2025 at 4:45 p.m. A beige piece of medical equipment was visible in the resident's room on the night stand next to the bed and plugged into the wall. Resident #1 lifted his shirt and a white gauze with a small amount of dried maroon colored drainage covered with a large clear adhesive bandage was noted to the left chest wall. There was no date noted on the dressing. Resident #1 stated he was in the hospital recently for a stroke and a loop recorder was put in his chest. Resident #1 stated the doctor at the local hospital told him to plug in the medical equipment for the loop recorder to monitor his heart. Resident #1 stated the medical equipment had been in his room plugged in since his readmission on 01/24/2025. The resident stated the dressing was applied at the hospital and the facility staff had not removed the dressing since his readmission on 01/24/2025. He stated the facility staff had not spoken to him about or addressed the surgical incision, loop recorder, or the equipment used to monitor his heart rate since he was readmitted to the facility. An observation was made of Resident #1 on 02/19/2025 at 9:03 a.m. Resident #1 lifted his shirt and a dressing was observed on his left chest wall. The dressing was a white gauze with a small amount of dried maroon drainage covered with a clear adhesive bandage was noted to the left chest wall. A telephone interview was conducted on 02/20/2025 at 12:33 p.m. with S10LPN. S10LPN stated she was responsible for providing the facility with resident's hospital documentation. S10LPN stated she provided the facility with Resident #1's hospital records from 01/20/2025 through 01/22/2025, but did not send the records from 01/23/2025 through 01/24/2025. S10LPN stated she sent the hospital AVS orders via email on 01/24/2025 to S2DON, S11ADON and S9LPN for review, which included the loop recorder discharge instructions. S10LPN stated S2DON, S11DON and S9LPN should have reviewed the AVS orders to ensure further information was not needed. She stated the note from the hospital case manager stated Resident #1's hospital nurse gave report on 01/24/2025 at 4:16 p.m. to the facility nurse so she did not provide the facility with the paperwork from the 23rd or 24th. An interview was conducted on 02/19/2025 at 4:30 p.m. with S9LPN. S9LPN stated she would assist with completion of resident admission and readmission order entry. She stated the admissions or readmission process was, S10LPN would send an email to dietary, S11ADON, S2DON and herself, which included the AVS orders from the hospital, which they review and follow as orders and instructions from the hospital for residents' care. S9LPN stated from the email received she will print out the AVS and the residents' current physician orders. She stated she will use the residents' current physician order to compare against the AVS and enter new orders or discontinue orders according to the AVS. S9LPN confirmed she did not review part of the AVS titled Local Hospital Facility Transfer Orders, which included the discharge instructions regarding loop recorder incision care. S9LPN confirmed since she failed to review the discharge instructions in the entirety, no orders were entered for Resident #1's loop recorder incision care. After review of Resident's NP Progress Notes, S9LPN stated she did see the S6NP's progress notes on 01/25/2025 during MDS assessment completion, but overlooked the note where loop recorder was placed and the left chest wall incision in the NP's Progress Notes and only looked at the S6NP's plan at the bottom of the note. S9LPN stated the floor nurse who would be receiving Resident #1 for readmission would have received report from the hospital nurse before the resident came to the facility and S9LPN would give a copy of AVS to the admission nurse. S9LPN stated she would have given the copy to S3LPN because he worked on Fridays. S9LPN reviewed Resident #1's electronic health record (EHR) and confirmed Resident #1 did not receive treatment or monitoring for the surgical incision upon readmission to the facility on [DATE] to present. S9LPN confirmed she did not contact the physician to clarify whether incision orders were needed or not. S9LPN stated she was not sure of who the cardiologist was or who had been monitoring the loop recorder. S9LPN confirmed Resident #1 did not have a cardiologist follow up appointment scheduled and should have A telephone interview was conducted on 02/19/2025 at 12:00 p.m. with S3LPN. S3LPN stated he worked on 01/24/2025 and 01/25/2025 and was responsible for Resident #1's readmission to the facility. S3LPN stated the admission or readmission process for the admission nurse to receive report from the local hospital. S3LPN stated the local hospital will fax an AVS packet over to the facility and those orders from the AVS are entered into the physician orders by S11ADON or whoever is available. S3LPN stated he was responsible to review the AVS orders against the current Physician orders as a check and balance that the AVS orders are entered correctly. S3LPN stated he reviewed Resident #1's AVS paperwork from the hospital on readmission and did not recall discharge loop recorder incision instructions. S3LPN confirmed he did see a new dressing on Resident #1, during readmission and during weekly skin assessments, but he did not assess or remove the dressing. S3LPN stated he assumed wound care was taking care of the incision and dressing. S3LPN confirmed he did not call the physician for dressing or incision order clarifications or notify S2DON or wound care of the new incision. S3LPN stated when residents are admitted or readmitted a full body and skin assessment should be completed by the nurse to assess the skin for wounds, developing wounds or any issues with the resident's skin and document in the residents' EHR. S3LPN confirmed there were no orders or care implemented for Resident #1's surgical incision or monitoring of the loop recorder equipment from 01/24/2025 through 02/17/2025. A telephone interview was conducted on 02/19/2025 at 12:34 p.m. with S5LPN. S5LPN stated she cared for Resident #1 on the night shift of 01/24/2025. S5LPN stated she did review the discharge summary instructions for Resident #1, but failed to see discharge instructions for a surgical incision and loop recorder. S5LPN stated the process for the admitting nurse during a resident readmission from the hospital would be to complete a head to toe assessment, which included a full skin assessment and document the assessment in the nursing notes. S5LPN stated during the skin assessment the nurse would check for open areas, bruising, sores and any changes of the skin. S5LPN stated staff receive a copy of a resident's discharge summary instructions for review and a copy is kept at the nurses' station for reference. S5LPN stated she did not receive report of Resident #1 having any new skin wound or incision from S3LPN on the night of 01/24/2025. S5LPN confirmed since she did not receive report of the new incision she had not changed the dressing, completed any monitoring or cared for Resident #1's incision. S5LPN stated Resident #1 did notify her the hospital performed a surgical procedure to insert a device, but she did not report it or investigate further. S5LPN confirmed there were no orders to care for Resident #1's incision or equipment at the bedside. A telephone interview was conducted on 02/20/2025 at 10:46 a.m. with S6NP. S6NP stated she was aware Resident #1 was readmitted to the facility from the local hospital status post loop recorder placement. She stated she requested the nurse, who she could not recall, on 01/25/2025 to contact the hospital and request the AVS orders. S6NP confirmed Resident #1 did not receive care for his left chest wall dressing at the loop recorder insertion site, which caused a likelihood for Resident #1 to develop an infection. S6NP stated Resident #1's incision should have been treated or monitored, and was not. An interview was conducted on 02/19/2025 at 10:59 a.m. with S4LPN. S4LPN stated she provided care to Resident #1 from 01/24/2025 through 02/19/2025. S4LPN stated she did not receive report from staff or see any documentation in the EHR stating Resident #1 had a surgical wound or monitoring equipment. S4LPN stated after Resident #1 was readmitted on [DATE] he informed her he had a dressing, but she was unsure of the date. S4LPN stated she assumed someone was taking care of the dressing, and she did not further investigate the issue. S4LPN stated she observed the dressing to Resident #1's left chest wall. S4LPN confirmed she did not remove the dressing or assess the incision site. S4LPN stated she did not recall reporting the dressing to the wound care nurse, S2DON, or MD/NP. S4LPN stated if she reported the dressing and clarified wound care orders she would have documented this in the nursing notes. S4LPN stated she observed the dressing to Resident #1's left chest wall, but did not provide treatment because she did not have orders. S4LPN stated Resident #1 informed her of the monitoring for the cardiologist, but she did not see any equipment. S4LPN said she did not notify anyone of the dressing, the information about the monitoring equipment, or contact the physician to obtain clarification for treatment. A telephone interview was conducted on 02/20/2025 at 1:01 p.m. with S13WCN2. S13WCN2 stated she was responsible for providing resident wound care from 01/24/2025 through mid-February 2025. S13WCN2 confirmed staff did not report a surgical incision or dressing for Resident #1 nor had she provided any wound care to Resident #1 from 01/24/2025 to 02/17/2025. An interview was conducted on 02/19/2025 at 11:11 a.m. with S8WCN1. S8WCN1 stated she S8WCN1 stated Resident #1 had no orders for surgical incision care. S8WCN1 confirmed she did not provide any wound care to Resident #1 from her hire date in February 2025 to 02/17/2025. A telephone interview was conducted on 02/19/2025 at 9:48 a.m. with S7NP. S7NP confirmed he would expect the nurses to follow the AVS orders received from the hospital. S7NP stated he would expect the nurses to notify the facility's wound care nurse practitioner and wound care nurse, if there were no orders for a wound or incision. He stated he expected the nurse to monitor, as ordered, the incision and immediately report to him and the wound care nurse practitioner any signs and symptoms of decline in the incision, not healing properly and any other issues with the resident and/or incision. An interview was conducted on 02/20/2025 at 10:30 a.m. with S2DON. S2DON stated the admission and readmission process started with S10LPN who emailed the AVS instructions on 01/24/2025. S2DON stated upon Resident #1's readmission the facility received Resident #1's AVS orders via email from S10LPN. S2DON confirmed the email included the document titled local hospital facility transfer orders, which included the loop recorder incision discharge instructions. S2DON confirmed S9LPN was responsible for reviewing Resident #1's AVS and entering orders for resident care. S2DON stated S9LPN should have reviewed the AVS orders in its entirety and entered the loop recorder incision instructions into the EHR and did not. S2DON confirmed staff should have clarified orders with a physician when Resident #1 verbally notified staff of the incision and staff made observations of the incision. S2DON reviewed Resident #1's EHR and verified the resident did not receive care for loop recorder incision, from 01/24/2025 to 02/18/2025, or the subsequent monitoring equipment from 01/24/2025 through 02/20/2025, when the medical director was contacted for instructions. S2DON confirmed the cardiologist was not contacted until 02/19/2025. S2DON stated for Resident #1's readmitted d 01/24/2025 there was no admission evaluation or nursing note and there should have been. After review of Resident #1's EHR, S2DON confirmed there was no documentation regarding Resident #1's incision dressing, treatment, assessment, or monitoring. S2DON stated the progress notes are only monitored by the clinical administrative staff, if they have an adverse event or new orders and not necessarily on a readmission and then the clinical administrative staff will give a brief synapses during the morning meetings to catch up on the resident status as needed. She stated she did not receive report in the morning meetings about a surgical incision, loop recorder monitoring equipment. S2DON confirmed stated she was not aware and had not seen a device/equipment at Resident #1's bedside since readmission. A telephone interview was conducted on 02/24/2025 at 3:46 p.m. with the hospital cardiologist office nurse. She stated the first time they were contacted by the facility was on 02/21/2025, regarding a follow up appointment and requested the loop recorder equipment and incision instructions. She stated she expected the facility to call within a few days of readmission for a cardiologist follow up for an incision check and loop recorder monitoring equipment instructions and did not. After review of AVS orders and hospital medical records regarding loop recorder discharge instructions and follow up, she stated she would have expected the facility to follow the orders. She confirmed the adhesive dressing should have been removed at least 48 hours after the loop recorder was placed and a follow up for skin check by the cardiologist nurse or the nurse at the facility. She confirmed in order for the nurse to assess the incision the large clear adhesive dressing should have been removed to assess the incision, which is a little more than an inch long with white adhesive strips, for redness and drainage at least a week status post loop recorder placement. She stated if Resident #1 had symptoms of atrial fibrillation, they would be alerted and would call the facility to notify them the Resident #1 needed to be seen by the cardiologist. 3. Review of the facility's policy titled, Skin and Wound Management Guidelines undated, revealed the following, in part: Guidelines: Admission/Readmission 1. Staff nurse a. Complete the NSG Admission/Readmission Evaluation including a careful evaluation of the skin with thorough and descriptive documentation of any alteration in skin integrity. c. Provide detailed documentation of any alteration in skin integrity in the Progress Notes. d. Obtain and enter treatment order for any identified skin issues. e. Enter into the (TAR), including the following: i. monitoring each shift for presence and condition of dressing, if a dressing is used; ii. daily monitoring for signs of infection or drainage; iii. dressing changes as ordered. 2. Wound Care Nurse a. Review admissions/readmissions and conduct a thorough assessment and documentation of admission, on any wound being monitored. Review of Resident #1's local hospital records dated 01/19/2025 through 01/24/2025 revealed Resident #1's Hospital Cardiologist implanted a loop recorder on 01/24/2025. Review of Resident #1's Physician Orders from 10/31/2024 through 02/18/2025 revealed on 11/01/2024, an order was implemented for Weekly Skin Check - Document results on Weekly Skin Observation Assessment every day shift every 7 days. Review of Resident #1's Skin & Wound-Total Body Skin Assessments dated 01/31/2025, 02/07/2025, and 02/14/2025 revealed normal skin assessments with no new wounds or surgical incisions documented. Further revealed there was no assessment dated [DATE]. Review of Resident #1's Wound Care Evaluations from 10/31/2024 to current revealed no documentation for left chest wall surgical incision treatment, assessment and/or monitoring and no other wounds. Review of Resident #1's Nursing Notes from 01/01/2025 through 02/18/2025 revealed no evidence of Resident #1's surgical incision site or the loop recorder monitoring equipment. A telephone interview was conducted on 02/19/2025 at 12:00 p.m. with S3LPN. S3LPN stated he worked on 01/24/2025 and 01/25/2025 and was responsible for Resident #1's readmission to the facility. S3LPN stated when he completed the weekly skin body audits on 01/31/2025, 02/07/2025 and 02/14/2025, he did not document Resident #1's surgical incision. S3LPN stated a new wound or new dressing should have on the aforementioned dates should have been documented new wound and MD/NP notified. S3LPN stated the wound care nurse should be notified of the new wound to request an assessment and treatment of the new wound or dressing and was not. S3LPN confirmed he did see a new dressing on Resident #1, during readmission and on the weekly skin assessments. S3LPN confirmed a readmission skin assessment should have been completed and had not been. S3LPN confirmed he completed a weekly skin assessment for the resident on 01/31/2025, 02/07/2025 and 02/14/2025 and did not document the surgical incision or dressing. S3LPN confirmed there were no orders for assessment, monitoring, or treatment implemented for Resident #1's surgical incision or monitoring equipment from 01/24/2025 through 02/17/2025. A telephone interview was conducted on 02/20/2025 at 10:46 a.m. with S6NP. S6NP stated she was aware Resident #1 was readmitted to the facility from the local hospital status post loop recorder placement. S6NP confirmed Resident #1 did not receive care for his left chest wall dressing at the loop recorder insertion site, which caused a likelihood for Resident #1 to develop an infection. S6NP stated Resident #1's incision should have been treated or monitored, and was not. An interview was conducted on 02/19/2025 at 10:59 a.m. with S4LPN. S4LPN stated she provided care to Resident #1 on her shifts from 01/24/2025 through 02/19/2025 S4LPN stated she did not receive report or see any documentation in the EHR stating Resident #1 had a surgical wound or monitoring equipment. S4LPN stated she observed the dressing to Resident #1's left chest wall, but did not provide treatment because she did not have orders. S4LPN said she did not notify anyone of the dressing or contact the MD/NP for orders. A telephone interview was conducted on 02/20/2025 at 1:01 p.m. with S13WCN2. S13WCN2 stated she was responsible for providing resident wound care from 01/24/2025 through mid-February 2025. S13WCN2 confirmed staff did not report a surgical incision or dressing for Resident #1 from 01/24/2025 to 02/17/2025. An interview was conducted on 02/19/2025 at 11:11 a.m. with S8WCN1. S8WCN1 stated Resident #1 had no orders for surgical incision care. S8WCN1 confirmed staff did not report a surgical incision for Resident #1 from her hire date in February 2025 to 02/17/2025. A telephone interview was conducted on 02/19/2025 at 9:48 a.m. with S7NP. S7NP confirmed he would expect the nurses to follow the AVS orders received from the hospital. S7NP stated he would expect the nurses to notify the facility's wound care nurse practitioner and wound care nurse, if there were no orders for a wound or incision. He stated he expected the nurse to monitor, as ordered, the incision and immediately report to him and the wound care nurse practitioner any signs and symptoms of decline in the incision, not healing properly and any other issues with the resident and/or incision. An interview was conducted 02/20/2025 at 10:30 a.m. with S2DON. S2DON confirmed the nurse was expected to conduct a head to toe skin assessment and document accurate findings when a resident was readmitted to the facility and weekly. S2DON confirmed any nurse that observed a skin dressing on a resident without documentation or orders should contact the physician to clarify what treatment is needed. S2DON reviewed Resident #1's EHR and verified there was no documentation noting Resident #1 had a skin incision or monitoring equipment assessment, monitoring or treatment. An interview was conducted on 02/21/2025 at 1:00 p.m. with S1ADM. S1ADM stated the nursing staff had not completed nursing care assessment and monitoring for Resident #1's surgical incision per facility policy and procedure, which could have caused complications with his surgical incision. The facility implemented the following plan of removal to correct the deficient practice: Corrective Action 1) Orders reviewed and order clarification obtained on 02/20/2025 from PCP for loop recorder monitoring and maintenance to start after all staff providing care has been completed. 2) Full body skin assessment of Resident #1 completed on 02/19/2025. 3) An order was obtained to monitor Resident #1's left chest wall incision site every shift for tenderness and signs of infection starting 02/19/2025. Identification of others at risk l) All newly admitted or readmitted residents with surgical incisions or medical devices had the potential to be affected. Systemic Changes l) DON/designee will ensure all nursing staff (including agency) receive education on admission assessment, verifying, clarifying and accurately transcribing admission orders, as well as training on proper completion of skin assessments and body audits. This training was started on 02/19/2025 and completed 02/21/2025. All future incoming employees and agency workers will be trained prior to being allowed to provide any treatment. 2) The admitting nurse will call the PCP to hospital discharge orders and obtain clarification as needed. Once orders are verified the admission nurse will accurately transcribe new orders into the EHR and a second nurse will confirm orders for accuracy, to start on 02/21/2025. 3) Clinical administrative staff will review all newly admitted residents discharge orders, admission orders, and admission assessments to ensure accuracy and completion during morning clinical meeting daily starting on 02/21/2025. Monitoring 1) DON/designee to complete random audits of newly admitted /readmitted residents discharge orders, admission orders and admission assessments for completion and accuracy weekly x 4 weeks then monthly x 2 months. 2) Audit trends will be reported to facility QAPI for review and further recommendations. 3) The facility asserts the likelihood for serious harm to any recipient no longer exists as of 02/21/2025. Throughout the survey from 02/20/2025 to 02/21/2025, observations, interviews, and record review revealed the above listed actions were implemented. Random staff interviews revealed the above education for staff was completed and monitoring by S2DON was started as mentioned above in the POR.

Based on interviews and record review the facility failed to ensure resident records were maintained and accurate in accordance with accepted professional standards and practices for 1 (#1) of 5 (#1, #2, #3, #4, and #5) sampled residents' records reviewed. The facility failed to ensure staff: 1. Accurately completed readmission assessment for Resident #1; 2. Maintained documented blood pressure readings with blood pressure medication administration for Resident #1; and 3. Accurately documented weekly skin assessments for Resident #1. Findings: Review of facility's policy titled Administration Resident Records-Identifiable Information, dated 02/2023 revealed the following, in part: Policy: The facility will maintain a complete, accurate, readily accessible and systematically organized medical record, in accordance with accepted professional standards and practices, for each resident. Guidelines: 1. The medical record will reflect a resident's progress toward achieving their person-centered plan of care objective goals and the improvement and maintenance of their clinical and functional status. 2. The medical record will reflect the resident's condition and the care and services provided across disciplines to facilitate communication among the interdisciplinary team. 4. The medical record will contain: b. A record of the resident's assessments; e. nurse progress notes; Review of Resident #1's Clinical Records revealed he was readmitted to the facility from the hospital on 01/24/2025 with diagnoses, which included Acute Arterial Ischemic Stroke and Hypertension 1. Review of Resident #1's Re-Admission Evaluation dated 01/24/2025 revealed no readmission assessment documentation. Review of Resident #1's Nursing Notes dated 01/24/2025 revealed no readmission assessment note. A telephone interview was conducted on 02/19/2025 at 12:00 p.m. with S3LPN. S3LPN stated he readmitted Resident #1 to the facility on [DATE]. S3LPN stated upon Resident #1's readmission, a complete and accurate physical and skin assessment should have been documented in the Electronic Health Record (EHR) and was not. An interview was conducted on 02/20/2025 at 10:30 a.m. with S2DON. S2DON confirmed when a readmission assessment was performed, she expected nursing staff to conduct a head to toe physical and skin assessment and document accurate findings in an readmission evaluation and/or nursing notes. S2DON reviewed Resident #1's Electronic Health Records (EHR) and confirmed there was no readmission evaluation or nursing notes regarding the readmission assessment and should have been. 2. Review of Resident #1's current Physician Orders revealed the following, in part: Start date: 01/25/2025. Lisinopril tablet 10 milligram, give 1 tablet by mouth one time a day related to essential (primary) hypertension, hold if blood pressure less than 110/60 and notify Nurse Practitioner (NP). Review of Resident #1's Medical Administrative Record (MAR) from 01/25/2025 to 02/17/2025 revealed no documented blood pressure readings. Review of Resident #1's vital sign records from 01/25/2025 through 02/17/2025 revealed no documented blood pressure readings. A telephone interview was conducted on 02/18/2025 at 11:02 a.m. with S3LPN. S3LPN confirmed in Resident #1's EHR from 01/25/2025 to 02/17/2025 there were no blood pressure readings documented in conjunction with Lisinopril medication administration and there should have been. An interview was conducted on 02/18/2025 at 4:15 p.m. with S4LPN. S4LPN stated when she took care of Resident #1 on her shifts from 01/25/2025 to 02/17/2025, she documented the blood pressure results on her personal nursing flowsheets and could not readily produce these documents because they were discarded in the shredder. After review of Resident #1's EHR from 01/25/2025 to 02/17/2025, she confirmed there were no blood pressure readings documented in conjunction with Lisinopril medication administration and there should have been. An interview was conducted on 02/18/2025 at 3:45 p.m. with S2DON. S2DON stated nursing staff have personal nursing flowsheets to document residents' vital signs, but were not part of residents' EHR. After review of Resident #1's EHR from 01/25/2025 through 02/17/2025, S2DON confirmed there were no blood pressure readings documented in conjuction with Lisinopril medication administration and should have been. 3. Review of Resident #1's local hospital records admission, 01/19/2025, through discharge, 01/24/2025, revealed an implanted loop recorder was implanted on the left chest wall on 01/24/2025. Review of Resident #1's current Physician Orders revealed on 11/01/2024, an order was implemented for Weekly Skin Check - Document results on Weekly Skin Observation Assessment every day shift every 7 days. Review of Resident #1's weekly Skin Observation assessment dated [DATE], 02/07/2025, and 02/14/2025 revealed normal skin assessments with no new wounds or surgical incisions documented. Review of Resident #1's Nursing Notes from 01/24/2025 through 02/18/2025 revealed no documentation of Resident #1's surgical incision site. An interview was conducted on 02/19/2025 at 12:00 p.m. with S3LPN. S3LPN confirmed he observed a new dressing on Resident #1 and did not accurately document the new wound or incision on the 01/31/2025 weekly skin observation assessment and should have. An interview was conducted on 02/20/2025 at 10:30 a.m. with S2DON. S2DON confirmed nursing staff was expected to conduct a head to toe skin assessment and document accurate findings when a weekly skin assessment was performed as ordered. S2DON confirmed when nursing staff observed a new wound or incision it should be accurately documented on the weekly skin observation assessment. S2DON confirmed Resident #1 had a new incision on the left chest wall from a loop recorder implantation on 01/24/2025. S2DON reviewed Resident #1's weekly skin observation assessment dated [DATE] and verified there was no documentation of a new incision and should have been.

Based on interviews and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 (#1) of 3 (#1, #2, and #3 ) sampled residents, by failing to ensure Resident #1 was coded for a surgical wound. Findings: Review of Resident #1's Clinical Records revealed he was admitted to the facility on [DATE] with diagnoses, which included Cerebral Infarction. Further review revealed Resident #1 was readmitted on [DATE]. Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/30/2025 revealed Resident #1 was not coded for surgical wounds in Section M: Skin Conditions, Line M1040-Other Ulcers, Wounds, and Skin Problems. Review of Resident #1's Nurse Practitioner (NP) Progress notes dated 01/24/2025 through 02/18/2025 revealed the following, in part: On 01/25/2025 at 5:40 p.m., S6NP noted under Admission History and Physical section: Cardiovascular: Left Chest Wall dressing with scant bloody drainage status post loop recorder placement. On 01/26/2025 at 3:20 p.m., S6NP noted under Physician/Practitioner Note section: Cardiovascular: Left Chest Wall dressing with scant bloody drainage status post loop recorder placement. An interview was conducted on 02/19/2025 at 4:30 p.m. with S9LPN. S9LPN stated upon completion of Resident #1's Quarterly MDS with an ARD of 01/30/2025, she reviewed the aforementioned S6NP's progress notes and overlooked the Cardiovascular section of the note, which indicated Resident #1 had a left chest wall dressing with scant bloody drainage status post loop recorder placement. S9LPN confirmed Resident #1's Quarterly MDS with an ARD of 01/30/2025 did not accurately reflect Resident #1's status by reflecting he had a surgical wound. An interview was conducted on 02/24/2025 with S2DON. S2DON reviewed Resident #1's Quarterly MDS with an ARD of 01/30/2025, and confirmed the assessment did not accurately reflect Resident #1's status by reflecting he had a surgical wound and should have.

Based on interviews and record review, the facility failed to include a resident's medical and nursing needs for a surgical incision and loop recorder monitoring equipment with measurable objectives and timeframes for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for Care Plans. Findings: Review of the facility's policy titled, Comprehensive Care Plans dated 03/2023 revealed the following in part: Purpose: To provide each resident with a person-centered, comprehensive care plan to address the resident's medical, nursing, physical, mental and psychosocial needs. Guidelines: 1. The care plan will be comprehensive and person-centered. It will drive the type of care and services that resident receives and will describe the resident's medical, nursing, physical, mental and psychosocial needs and preferences; as well as how the facility will assist in meeting those needs and preferences. 11. The care planning process will be an on-going process. 12. Resident care needs and care plan interventions will be communicated with direct care staff Review of Resident #1's Clinical Records revealed he was admitted to the facility on [DATE] with diagnoses, which included Cerebral Infarction and Monoplegia. Further review revealed Resident #1 was readmitted on [DATE]. Review of Resident #1's After Visit Summary Discharge Instructions Orders (AVS) for local hospital admitted d 01/19/2025 through 01/24/2025 revealed the following, in part: Primary diagnosis was Acute Arterial Ischemic Stroke, Multifocal, and Multiple Vascular Territories. Further review revealed Local Hospital Facility Transfer Orders included discharge instructions for loop recorder: You may shower in 24 hours after the procedure. Allow soapy water to gently run over chest incision, not directly on incision. Do not rub or scrub incision. No bathtubs or submerging in water until site is completely healed. Keep site clean and dry at all times. Inspect site daily for tenderness, discharge, or signs of infection. Apply ice pack for 24 hours. Do not remove the white adhesive strips, allow them to fall off on their own. Review of Resident #1's Nurse Practitioner (NP) Progress notes from 01/24/2025 through 02/18/2025 revealed the following, in part: 01/25/2025 at 5:40 p.m., S6NP- Admission History and Physical: HPI: Resident #1 sent to the emergency room and he was admitted for evaluation of possible Cerebral Vascular Accident (CVA). Loop recorder was placed while inpatient. Cardiovascular: Left Chest Wall dressing with scant bloody drainage status post loop recorder placement. 01/26/2025 at 3:20 p.m., S6NP- Physician/Practitioner Note: Cardiovascular: Loop recorder placed. Cardiovascular: Left Chest Wall dressing with scant bloody drainage status post loop recorder placement. Assessment/Plan: loop recorder Review of Resident #1's current Care Plan revealed no care plan problem or intervention for a surgical incision to the left chest wall and/or the loop recorder equipment. An observation was made of Resident #1 on 02/17/2025 at 4:45 p.m. Resident #1 was observed in his room and a beige medical equipment was visible on the night stand next to the bed plugged in. Resident #1 lifted his shirt and a dressing was observed on his left chest wall. The dressing was a white gauze with a small, dried, maroon drainage covered with a large clear adhesive with rolled edges and was not dated. An interview was conducted on 02/17/2025 at 4:45 p.m. with Resident #1. Resident #1 stated he was in the hospital recently for a stroke and they put in a loop recorder in his chest. Resident #1 stated the doctor at the Local Hospital told him to plug in the medical equipment for the loop recorder that was given to him at discharge to monitor his heart. Resident #1 stated the medical equipment had been in his room plugged in since his readmission on 01/24/2025. An observation was made of Resident #1 on 02/19/2025 at 9:03 a.m. Resident #1 observed in his room. He lifted his shirt and a dressing was observed on his left chest wall. The dressing was a white gauze with a small, dried, maroon drainage covered with a large clear adhesive with rolled edges. An interview was conducted on 02/19/2025 at 4:30 p.m. with S9LPN. S9LPN stated she was the Care Plan nurse and Readmission nurse for Resident #1. S9LPN stated upon Resident #1's readmission on 01/24/2025, she reviewed the AVS orders and overlooked part of the orders with the title [Local Hospital] Facility Transfer Orders, which included discharge instructions for loop recorder incision care and monitoring. S9LPN stated upon further review of Resident #1's electronic health record (EHR) she reviewed the aforementioned S6NP's progress notes and overlooked the Cardiovascular section of the note, which indicated Resident #1 had a Left Chest Wall dressing with scant bloody drainage status post loop recorder placement and did not update Resident #1's Care Plan to reflect Resident #1's status. S9LPN confirmed Resident #1's Care Plan did not include medical and nursing needs for a surgical wound and/or loop recorder monitoring equipment with measurable objectives and timeframes and should have been. An interview was conducted on 02/24/2025 with S2DON. S2DON reviewed Resident #1's Care Plan from 01/24/2025 through 02/18/2025 and confirmed the Care Plan did not include medical and nursing needs for a surgical wound and/or loop recorder monitoring equipment with measurable objectives and timeframes and should have been.

Based on interviews and record reviews, the facility failed to protect a resident's right to be free from sexual and psychosocial abuse for 1(#33) of 12 (#13, #14, #24, #31, #33, #61, #74, #77, #190, #191, #192, and #193) residents reviewed for sexual and psychosocial abuse. The facility failed to ensure Resident #33 was not sexually abused by S5MAIN. This deficient practice resulted in an Immediate Jeopardy (IJ) situation for Resident #33, a cognitively impaired blind resident, on 01/08/2025, when it was discovered that during the Christmas/New Year Holiday Season, S8CNA witnessed S5MAIN sitting on Resident #33's bed, rubbing the resident's shoulder, and kissed her on the cheek. S8CNA failed to report the sexual abuse and S5MAIN continued to work in the facility until 01/02/2025 at 5:00 p.m. On 01/05/2025, #R1 reported S5MAIN sat down next to Resident #33 on her bed, rubbed Resident #33's back and arm, kissed her cheek and neck and said he wanted to see her beautiful cat again. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Resident #33, it could be determined the reasonable person would have experienced severe psychosocial harm as a result of the sexual abuse, since a reasonable person would not expect to be treated in this manner in their own home or a health care facility. S1ADMIN was notified of the Immediate Jeopardy situation on 01/10/2025 at 6:09 p.m. The Immediate Jeopardy situation was removed on 01/12/2025 at 2:15 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at the potential for more than minimal harm for the remaining 92 residents residing in the facility. Findings: Review of the facility policy titled Abuse, with a revision date of 05/15/2023, revealed the following, in part: Intent: To promote a safe environment for residents, visitors, and employees through prompt and appropriate response and follow up to abuse allegations and events. Definitions: Sexual Abuse: Non-consensual sexual contact of any type with a resident. Responsibilities of Facilities and Covered Individuals 2. The facility will immediately protect the resident from further potential abuse while the investigation is in progress. This includes: a. Removing employee/s from duty when an allegation has been made until the investigation has been completed and a determination has been made. c. Implementing increased supervision as necessary for alleged perpetrator and alleged victim. d. Conducting interviews with other residents and staff. e. Monitoring the alleged victim and intervening as appropriate, for indications of physical injury, pain, or psychosocial distress. Review of Resident #33's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following cerebral infarction affecting the left non-dominant side, Unspecified Dementia, Difficulty in Walking, Cognitive Communication Deficit and Legal Blindness. Review of Resident #33's Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 08/01/2024 revealed Resident #33 had a Brief Interview for Mental Status (BIMS) of 08, which indicated the resident had moderate cognitive impairment. Review of Resident #33's current Care Plan revealed the resident was blind, cognitively impaired with a BIMS of 8, and required assistance with ADLS to include transfer assistance and a wheelchair for mobility. On 01/06/2025 review of the facility's self-reported incident dated 01/05/2025 at 9:59 p.m. revealed: Resident Victim: Resident #33 Accused: S5MAIN Accused Allegations: Sexual Abuse Incident Description: #R1 told S6CNA that she saw S5MAIN kissing her roommate (Resident #33) on the forehead and the cheek. She says that she overheard S5MAIN tell Resident #33 he could see her cat when she was walking naked in the hallway. Review of #R1's witness statement revealed the following, in part: On 01/03/2025, Friday, at approximately 4:30 p.m., S5MAIN sat on Resident #33's bed, began to rub her back and arm and began peck kissing her left cheek. S5MAIN whispered to Resident #33. He told her how beautiful she was, and he had seen her cat (vagina) the other day when she was running down the hall. He told Resident #33 that her cat was special. I spoke up and told him he needed to get out then closed my curtain because was disgusting and unacceptable. Before he left the room he told Resident #33 he would bring her more coffee. Review of S20LPN's witness statement dated 01/05/2025 at 9:00 p.m. and 9:15 p.m. revealed the following, in part: Performed complete head to toe body audit on Resident #33. No markings, scratching, soreness noted. No pain or discomfort. Resident #33 does not recall anything. Review of S5MAIN witness statement dated 01/06/2025 revealed the following, in part: I don't really remember, but I was having a conversation about my and Resident 33's meeting when she was in the hall outside of her room with her cat hanging out. Her words not mine. Just kind of introducing her to her new roommate describing what a special Resident #33 was. I then gave Resident #33 a kiss on her head. I think she wasn't feel well that day and I had no coffee to get her. On 01/07/2024 at 9:00 a.m., an interview was conducted with S1ADMIN. S1ADMIN stated on 01/05/2025, #R1 reported to S6CNA that she had witnessed S5MAIN kissing Resident #33. #R1 reported S5MAIN was heard telling Resident #33 he had seen her cat when she was walking naked. Review of S5MAIN's personnel file revealed he began working in the facility on 09/30/2024. On 01/07/2024 at 9:54 a.m. an interview was conducted with Resident #33. Resident #33 stated she could not see. The resident was oriented to person, but was unable to answer questions due to cognitive impairment. During the interview, Resident #33 repeatedly stated she liked and wanted coffee. Resident #33 was unable to recall if anyone had kissed or touched her inappropriately. On 01/07/2025 at 10:20 a.m. an interview was conducted with #R1. #R1 reported Resident #33 was her roommate. #R1 said Resident #33 could not see, had dementia and did not always know what was going on, and always wanted coffee. #R1 stated approximately a week ago, she was in her room in bed when S5MAIN came into the room with a handheld drill. #R1 stated Resident #33 was asleep in bed. The resident stated S5MAIN walked over to Resident #33's bed, tried to wake her up by whispering to her and rubbing her back and arm. #R1 stated S5MAIN kissed Resident #33's left cheek. She stated S5MAIN woke Resident #33 up and asked her if she wanted coffee, then left the room and returned with a cup of coffee that he gave to Resident #33. She stated S5MAIN sat down next to Resident #33 on her bed, began to rub Resident #33's back and arm, and again kissed her on the cheek and the neck. #R1 stated other staff members witnessed S5MAIN sitting on Resident #33's bed. #R1 stated she heard S5MAIN tell Resident #33 he wanted to see her beautiful cat again, and that he had seen her beautiful cat while she was naked in the hall. #R1 stated Resident #33 seemed to be in shock and asked S5MAIN to move over and said to S5MAIN he shouldn't be sitting on her bed. She said Resident #33 told S5MAIN to give her some space. #R1 said S5MAIN told Resident #33 he was going to come back later. She stated she was scared to report the incident and waited until one of the CNA's she trusted returned to work. #R1 said she reported the incident to S6CNA with another staff member present on 01/05/2025. #R1 said after she reported it the other staff member stated another one. Review of #R1's MDS with an ARD of 12/26/2024 revealed the resident was admitted to the facility on [DATE] and had a BIMS of 15, which indicated the resident was cognitively intact. An interview was conducted on 01/07/2025 at 12:01 p.m. with S6CNA. She stated on 01/05/2025, #R1 reported to her that approximately a week ago, she was in her room in bed when S5MAIN came into the room. She stated #R1 reported S5MAIN walked over to Resident #33's bed, leaned over Resident #33, rubbed her arm and back, kissed her, and asked her if she wanted coffee. S6CNA stated #R1 reported she heard S5MAIN tell Resident #33 he had seen her cat meaning vagina. S6CNA stated she told S4LPN about what #R1 reported. S4LPN responded that she should have reported what S5MAIN had done to her sooner because if she had S5MAIN would not have been able to do this to Resident #33. S6CNA explained S5MAIN was suspended last week for pulling S4LPN's pants down without consent while on duty. S6CNA stated after speaking with S4LPN, she reported the incident to S3RN. A telephone interview was conducted on 01/07/2025 at 12:32 p.m. with S5MAIN. S5MAIN stated Resident #33 liked coffee and he would sometimes bring her some in her room and at other times would go visit her in her room. S5MAIN said he went into Resident #33's room sometime around Christmas, to tell her merry Christmas. He also stated he went into the Residents room recently to welcome #R1 to the facility. He stated the last time he went into the room, Resident #33's roommate was awake and in the room. He confirmed he sat on the residents' bed while she was in it and kissed the resident on the forehead and again on her cheek. He said he thought it was appropriate to kiss Resident #33 because they had developed a close relationship. S5MAIN stated he told #R1 that he had seen her in the hallway when she was only wearing a shirt. He stated Resident #33 asked him if he had never seen a cat before. S5MAIN stated after speaking with the resident he kissed her again on the forehead and the cheek. S5MAIN stated he was suspended from the facility on 01/02/2025 and refused to speak about why. On 01/07/2025 at 1:30 p.m., an interview was conducted with S4LPN. S4LPN said on 12/10/2024, S5MAIN followed her into her office, S5MAIN closed and locked the office door, advanced towards her from behind, pulled her pants down and touched her inappropriately with his hand on her buttocks. She stated she did not report the incident to anyone at the facility because she was scared. S4LPN said on 01/01/2025, S5MAIN came into her office again and said I know there isn't anybody here today and I want to look at your hole in what she perceived as a sexually suggestive tone, raising his eyebrow, and leaning towards her. He began to tell her what he wanted to do to her hole which made her feel uncomfortable and scared so she ran out of the room. She said after she ran out of the room, she reported both the 12/10/2024 and 01/01/2025 incidents with S5MAIN to S2DON on 01/01/2025. She said S2DON began monitoring S5MAIN to make sure nothing else happened to staff or residents. S4LPN stated on 01/02/2025, S1ADMIN was notified of the 12/10/2024 and 01/01/2025 incidents, and S5MAIN was suspended. S4LPN stated she should have reported the 12/10/2024 incident immediately to S2DON and S1ADMIN, but did not. Throughout the interview, S4LPN was observed to become tearful and stated S5MAIN would not have been able to hurt Resident #33 if she had told S2DON or S1ADMIN what happened on 12/10/2024. S4LPN stated she received abuse training within the last 90 days, but not after 01/01/2025. An interview was conducted on 01/07/2025 at 3:56 p.m. with S7CNA. He stated a few weeks ago, S4LPN reported to him that S5MAIN made a physical sexual advance towards her. S7CNA also stated that S8CNA recently told him she saw S5MAIN sitting on Resident #33's bed, talking to her and making inappropriate sexual statements. S7CNA stated on 01/05/2025, #R1 told him she had witnessed S5MAIN sitting on Resident #33's bed, talking to her and making inappropriate sexual statements. S7CNA stated it was not appropriate for S5MAIN to sit on Resident #33's bed and make inappropriate sexual comments to the resident. He stated other employees said S5MAIN exhibited weird behaviors, but he did not know what that meant. S7CNA said he never reported anything to his supervisor or the administrator. An interview was conducted on 01/08/2025 at 1:13 p.m. with Resident #33's sister. She stated Resident #33 had dementia and was not cognitively intact. She stated she was notified of an incident involving Resident #33 and a worker at the facility on 01/05/2025. She stated an employee of the facility told her a male worker kissed Resident #33 on her jaw and inappropriately touched/stroked her back and arm with his hands. She stated Resident #33 would not want an unknown male kissing and touching her. She stated, if Resident #33 had all her cognitive abilities, the resident would have suffered serious psychosocial harm from the male staff kissing and touching her while in her bed. She stated Resident #33 wouldn't want that person near her and would have been fearful. On 01/08/2024 at 2:24 p.m., an interview was conducted with S18LPN. She stated she was familiar with Resident #33. She stated Resident #33 was confused at baseline and would have different levels of confusion at different times. On 01/08/2024 at 2:28p.m., an interview was conducted with S19LPN. She stated she was familiar with Resident #33. She stated Resident #33 was confused at baseline and would have different levels of confusion at different times. On 01/08/2025 at 2:40 p.m., and interview was conducted with S8CNA. She stated at some time between Christmas and New Year's Day she was checking on the residents and saw S5MAIN in Resident #33's room. She stated she saw S5MAIN bring Resident #33 a cup of coffee. She stated S5MAIN sat on Resident #33's bed, talked to her, rubbed the resident's shoulder with his hand, and then kissed her on the cheek. S8CNA stated she could not hear what S5MAIN was saying. S8CNA stated #R1 was in the room. S8CNA stated she thought it was strange that someone from the maintenance department was that chummy with a resident. She stated she had seen S5MAIN in Resident #33's room before, but she had not seen him sitting on the bed before. She stated the observation made her feel uncomfortable and she thought it was inappropriate. She stated she did not report the incident to administration and thought she would have if it happened again. She stated she did communicate what she saw with another CNA. She confirmed she was trained on abuse prior to the incident and confirmed she should have reported what she saw because it was sexual abuse. An interview was conducted on 01/10/2025 at 1:36 p.m. with S2DON. S2DON said on 01/01/2025, S4LPN accused S5MAIN of sexual assaulting her. She stated after S4LPN reported the accusation of sexual assault, she began visually monitoring S5MAIN to make sure nothing happened to any of the staff or residents. S2DON stated S5MAIN's behavior was somewhat weird and quirky, and after a few hours of monitoring him, she told him he could leave for the day. She stated she did not monitor to see if S5MAIN actually left the facility. She stated on 01/02/2025, she reported the allegation to the administrator and S5MAIN was removed from the facility. S2DON said Resident #33 had a BIMS of 8 and had cognitive impairment. S2DON stated on 01/05/2025, around 6:00 p.m., S3RN reported #R1 had witnessed S5MAIN in her room with Resident #33. #R1 reported S5MAIN kissed Resident #33's forehead and cheek, rubbed Resident #33's arm and back, and made sexually inappropriate comments to Resident #33. S2DON stated she immediately contacted S1ADMIN and the Regional Director of Clinical. She reported, after S3RN reported S5MAIN had allegedly sexually abused Resident #33, the facility began an investigation to include interviewing #R1 and S20LPN completed a body audit on Resident #33. She stated Resident #33 was interviewed and unable to state if someone had sexually abused her, but the DON said due to Resident #33's cognitive impairment, she would not take her word. She stated the police were not notified. S2DON stated she did not know any of the facility staff had witnessed the incident and confirmed the staff that witnessed it should have immediately reported it so Resident #33 could have been protected. An interview was conducted on 01/10/2025 at 2:30 p.m. with S1ADMIN. S1ADMIN said Resident #33 had dementia. S1ADMIN stated on 01/05/2025, around 7:00 p.m., S2DON told him #R1 reported she witnessed S5MAIN kiss Resident #33 on the forehead and heard S5MAIN make an inappropriate comment to Resident #33 about her cat. S1ADMIN stated he notified the Regional Administration and the facility began an investigation to include interviewing all cognitive female residents. S1ADMIN stated S5MAIN told him a few weeks ago he had seen Resident #33 naked in the hallway. S5MAIN explained he was in #R1 and Resident #33's room recently and spoke to them about seeing Resident #33 naked. He stated S5MAIN said after he spoke to the residents he left the room and kissed Resident #33 on her forehead while leaving. S1ADMIN stated S5MAIN was suspended from work on 01/02/2025 and left the facility sometime in the late afternoon or early evening. S1ADMIN stated he was not aware an employee had witnessed the incident between S5MAIN and Resident #33 and had not reported it. S1ADMIN stated he had not reported the incident to police because he did not think it involved inappropriate touching. Review of the Individual Employee Time Card revealed on 01/02/2024 S5MAIN clocked in to work at 8:30 a.m. and out at 5:00 p.m. Review of Both S5MAIN and S8CNA's Individual Employee Time Cards revealed the employees were both in the facility on the following dates and times. 12/31 from 3:09 p.m. too 5:15 p.m. 1/1 from 3:09 p.m. to 5:27 p.m. 01/02 from 3:18 p.m. 5:00 p.m. Plan of Removal The surveyor confirmed the following had been initiated and/or implemented prior to exit: Corrective Action: 1. The accused has not worked in the building since 01/02/2025 and is currently on indefinite suspension pending further review. 2. Resident #33 was evaluated by Nurse Practitioner [NAME] on 01/08/2025 with no findings. 3. DON/Designee has in-serviced all employees and agency staff prior to the beginning of their shift on abuse, noting sexual and verbal, and the proper reporting procedure and how to identify abuse and signs of abuse. Employees gave verbal returned demonstrations of types of abuse, signs and proper reporting procedures. 4. Social Services/Designee performed a psychosocial evaluation on Resident #33 on 01/10/2025 with no findings. 5. DON/Designee has consulted with outside psych services 01/11/2025 to evaluate Resident #33 for psychosocial harm and is scheduled 01/13/2025. 6. From these evaluations, if any concerns are identified, the facility will develop a plan of care to address any concerns, trauma, etc. that might be identified. 7. DON/Designee has put daily monitors in place on 01/10/2025 for each shift for Resident #33 that staff will ask resident does she feel safe in the facility with no psycho-social harm exhibited. 8. The administrator/Designee has reported the alleged violation of abuse to the police on 01/10/2025. Identification of others at risk: 1. DON/Designee has interviewed interviewable residents on 01/10/2025 to determine if they have experienced sexual/verbal abuse, and if they feel safe in the facility with no findings. 2. DON/Designee has observed non interviewable residents on 01/11/2025 for non-verbal psycho-social signs of sexual/verbal abuse with no findings. Systemic Changes: 1. DON/Designee has in-serviced all employees and agency personnel starting on 01/10/2025 and will educate all employees and agency staff prior to the beginning of their shift on abuse, noting sexual and verbal, and the proper reporting procedure and how to identify abuse and signs of abuse. Employees gave verbal returned demonstration of types of abuse, signs and proper reporting procedures. Monitoring: 1. Audits have been conducted and are ongoing by DON or designee on 10 residents questioning if they have experienced sexual/verbal abuse, and if they feel safe in the facility weekly x's 4 weeks, then monthly x's 2 months. 2. Audits have been conducted and are ongoing by DON or designee on 10 non interviewable residents to observe for any non-verbal signs of physical/sexual/verbal weekly x's 4 weeks, then monthly x's 2 months. 3. DON/Designee has conducted and is ongoing interview audits of 5 staff members from various shifts and departments to ensure that there has not been observations of inappropriate behavior between staff members and residents in the past 30 days with cognitively intact or cognitively impaired residents. 4. Audit trends will be reported to facility QAPI for review and further recommendations.

Based on interviews and record reviews, the facility failed to ensure allegations of sexual abuse were reported immediately to the facility's administrator and to law enforcement authorities in an appropriate timeframe for 1 (#33) of 12 (#13, #14, #24, #31, #33, #61, #74, #77, #190, #191, #192, and #193) residents reviewed for sexual abuse. The facility failed to ensure: 1. Staff immediately reported allegations of sexual abuse to the administrator; and 2. The Administrator reported allegations of sexual abuse to local law enforcement This deficient practice resulted in an Immediate Jeopardy (IJ) situation for Resident #33, a cognitively impaired blind resident, on 01/08/2025, when it was discovered that during the Christmas/New Year Holiday Season, S8CNA witnessed S5MAIN sitting on Resident #33's bed, rubbing the resident's shoulder, and kissed her on the cheek. S8CNA failed to report the sexual abuse and S5MAIN continued to work in the facility until 01/02/2025 at 5:00 p.m. On 01/05/2025, #R1 reported to S6CNA S5MAIN sat down next to Resident #33 on her bed, rubbed Resident #33's back and arm, kissed her cheek and neck and said he wanted to see her beautiful cat again. Administration was made aware of the incident on 01/05/2025 and failed to report the allegations of sexual abuse to local law enforcement. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Resident #33, it could be determined the reasonable person would have experienced severe psychosocial harm as a result of the sexual abuse, since a reasonable person would not expect to be treated in this manner in their own home or a health care facility. S1ADMIN was notified of the Immediate Jeopardy situation on 01/10/2025 at 6:09 p.m. The Immediate Jeopardy situation was removed on 01/12/2025 at 2:15 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at the potential for more than minimal harm for the remaining 92 residents residing in the facility. Findings: Cross Reference F600 Review of the facility policy titled Abuse, with a revision date of 05/15/2023, revealed the following, in part: Definitions: Sexual Abuse: Non-consensual sexual contact of any type with a resident. Responsibilities of Facilities and Covered Individuals 2. Reporting responsibilities for reasonable suspicion of a crime in accordance with State law: e. Sexual abuse Response to Allegations and Suspicions 1. Allegations may be verbal or in writing and will be reported to the administrator of the facility and other officials as required. Review of Resident #33's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following cerebral infarction affecting the left non-dominant side, Unspecified Dementia, Difficulty in Walking, Cognitive Communication Deficit and Legal Blindness. Review of Resident #33's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/01/2024 revealed Resident #33 had a Brief Interview for Mental Status (BIMS) of 08, which indicated the resident had moderate cognitive impairment. On 01/06/2025 review of the facility's self-reported incident dated 01/05/2025 at 09:59 p.m. revealed: Resident Victim: Resident #33 Accused: S5MAIN Accused Allegations: Sexual Abuse Protective Actions: Suspended Pending Outcome Incident Description: #R1 told S6CNA that she saw S5MAIN kissing her roommate (Resident #33) on the forehead and the cheek. She says that she overheard S5MAIN tell Resident #33 he could see her cat when she was walking naked in the hallway. An interview was conducted on 01/08/2025 at 1:13 p.m. with Resident #33's sister. She stated Resident #33 had dementia and was not cognitively intact. She stated she was notified of an incident involving Resident #33 and a worker at the facility on 01/05/2025. She stated an employee of the facility told her a male worker kissed Resident #33 on her jaw and inappropriately touched/stroked her back and arm with his hands. She stated Resident #33 would not want an unknown male kissing and touching her. She stated, if Resident #33 had all her cognitive abilities, the resident would have suffered serious psychosocial harm from the male staff kissing and touching her while in her bed. She stated Resident #33 wouldn't want that person near her and would have been fearful. An interview was conducted on 01/07/2024 at 10:20 a.m. with #R1. #R1 stated approximately a week ago, she was in her room in bed when S5MAIN came into the room, walked over to Resident #33's bed, tried to wake her up by whispering to her and rubbing her back and arm. #R1 stated S5MAIN kissed Resident #33's left cheek, sat down next to Resident #33 on her bed, began to rub Resident #33's back and arm, and again kissed her on the cheek and the neck. #R1 stated other staff members witnessed S5MAIN sitting on Resident #33's bed. #R1 stated she heard S5MAIN tell Resident #33 he wanted to see her beautiful cat again, and that he had seen her beautiful cat while she was naked in the hall. #R1 said she reported the incident to S6CNA a few days after she witnessed it. She stated when she reported it to S6CNA on 01/05/2025 another staff member was present on 01/05/2025. Review of #R1's MDS with an ARD of 12/26/2024 revealed the resident was admitted to the facility on [DATE] and had a BIMS of 15, which indicated the resident was cognitively intact. An interview was conducted on 01/08/2025 at 2:40 p.m. with S8CNA. She stated at some time between Christmas and New Year's Day, she was checking on the residents shortly after she reported for her shift after 3:00 p.m. and saw S5MAIN in Resident #33's room. She stated S5MAIN sat on Resident #33's bed, talked to her, rubbed the resident's shoulder with his hand, and then kissed her on the cheek. She stated the observation made her feel uncomfortable and she thought it was inappropriate. She stated she did not report the incident to administration and stated she would have if it happened again. She stated she did communicate what she saw with S6CNA and S7CNA. She confirmed she should have reported what she saw because it was sexual abuse. An interview was conducted on 01/07/2025 at 3:56 p.m. with S7CNA. S7CNA stated S8CNA recently told him she saw S5MAIN sitting on Resident #33's bed, talking to her and making inappropriate sexual statements. S7CNA stated on 01/05/2025, #R1 told him she had witnessed S5MAIN sitting on Resident #33's bed, talking to her and making inappropriate sexual statements. S7CNA said he never reported this to his supervisor or the administrator. An interview was conducted on 01/07/2025 at 12:01 p.m. with S6CNA. She stated on 01/05/2025, #R1 reported to her that approximately a week ago, S5MAIN came into the room, walked over to Resident #33's bed, leaned over Resident #33, rubbed her arm and back, kissed her, and asked her if she wanted coffee. S6CNA stated #R1 reported she heard S5MAIN tell Resident #33 he had seen her cat meaning vagina. S6CNA stated she reported #R1's allegations to S4LPN and S3RN. An interview was conducted on 01/10/2025 at 1:36 p.m. with S2DON. S2DON said Resident #33 had a BIMS of 8 and had cognitive impairment. S2DON stated on 01/05/2025, around 6:00 p.m., S3RN reported #R1 had witnessed S5MAIN in her room with Resident #33. #R1 reported S5MAIN kissed Resident #33's forehead and cheek, rubbed Resident #33's arm and back, and made sexually inappropriate comments to Resident #33. S2DON stated she immediately contacted S1ADMIN and the Regional Director of Clinical. S2DON stated she was not aware a staff member had witnessed the incident and confirmed the staff that witnessed it should have immediately reported it so Resident #33 could have been protected. An interview was conducted on 01/10/2025 at 2:30 p.m. with S1ADMIN. S1ADMIN said Resident #33 had dementia. S1ADMIN stated on 01/05/2025, around 7:00 p.m., S2DON told him #R1 reported she witnessed S5MAIN kiss Resident #33 on the forehead and heard S5MAIN make an inappropriate comment to Resident #33 about her cat. S1ADMIN stated S5MAIN told him a few weeks ago after he spoke to the residents he left the room and kissed Resident #33 on her forehead while leaving. S1ADMIN stated he was not aware an employee had witnessed the incident between S5MAIN and Resident #33 and had not reported it. S1ADMIN stated he had not reported the incident to police. Plan of Removal The surveyor confirmed the following had been initiated and/or implemented prior to exit: Corrective Action: 1. The accused has not worked in the building since 01/02/2025 and is currently on indefinite suspension pending further review. 2. Resident #33 was evaluated by the Nurse Practitioner on 01/08/2025. 3. DON/Designee has in-serviced all employees and agency staff prior to the beginning of their shift on abuse, noting sexual and verbal, and the proper reporting procedure and how to identify abuse and signs of abuse. Employees gave verbal returned demonstrations of types of abuse, signs and proper reporting procedures. 4. Social Services/Designee performed a psychosocial evaluation on Resident #33 on 01/10/2025. 5. DON/Designee has consulted with outside psych services 01/11/2025 to evaluate Resident #33 for psychosocial harm and is scheduled 01/13/2025. 6. From these evaluations, if any concerns are identified, the facility will develop a plan of care to address any concerns, trauma, etc. that might be identified. 7. DON/Designee has put daily monitors in place on 01/10/2025 for each shift for Resident #33 that staff will ask resident does she feel safe in the facility with no psycho-social harm exhibited. 8. The administrator/Designee has reported the alleged violation of abuse to the police on 01/10/2025. Identification of others at risk: 1. DON/Designee has interviewed interviewable residents on 01/10/2025 to determine if they have experienced sexual/verbal abuse, and if they feel safe in the facility with no findings. 2. DON/Designee has observed non interviewable residents on 01/11/2025 for non-verbal psycho-social signs of sexual/verbal abuse with no findings. Systemic Changes: 1. DON/Designee has in-serviced all employees and agency personnel starting on 01/10/2025 and will educate all employees and agency staff prior to the beginning of their shift on abuse, noting sexual and verbal, and the proper reporting procedure and how to identify abuse and signs of abuse. Employees gave verbal returned demonstration of types of abuse, signs and proper reporting procedures. Monitoring: 1. Audits have been conducted and are ongoing by DON or designee on 10 residents questioning if they have experienced sexual/verbal abuse, and if they feel safe in the facility weekly x's 4 weeks, then monthly x's 2 months. 2. Audits have been conducted and are ongoing by DON or designee on 10 non interviewable residents to observe for any non-verbal signs of physical/sexual/verbal weekly x's 4 weeks, then monthly x's 2 months. 3. DON/Designee has conducted and is ongoing interview audits of 5 staff members from various shifts and departments to ensure that there has not been observations of inappropriate behavior between staff members and residents in the past 30 days with cognitively intact or cognitively impaired residents. 4. Audit trends will be reported to facility QAPI for review and further recommendations.

Based on observations, record reviews and interviews, the facility failed to ensure the residents remained as free of accident hazards as possible for each resident who was transported in the facility's van via wheelchair for 1 (#1) of 8 (#1, #2, #3, #R1, #R2, #R3, #R4, and #R5) residents reviewed for accidents. The facility failed to secure Resident #1's safety (belt) during transport as recommended by manufacturer guidelines. This failed practice resulted in an actual harm for Resident #1 on 09/20/2023 when S2VD failed to properly restrain Resident #1 into the facility van. During transport, Resident #1 slid out of her wheelchair onto the van floor. Resident #1 was transferred to a local hospital on 09/20/2023 where x-ray revealed a Left Tibia Plateau Fracture extending to the Proximal Tibial Metaphysis. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the manufacture's user instructions for passenger lap belt use revealed, in part: B. Secure Passenger 1. Attach lap belts-Use integrated stiffeners to feed belts through openings between seat backs and bottoms, and/or armrest to ensure proper belt fit around occupant. a. On the aisle side, attach belt with female buckle to rear tie-down pin connector; ensuring buckle rest on passenger's hip. b. On the window-side, attach belt with male tongue to rear tie-down pin connector and insert into female buckle. 2. Attach Shoulder Belt-Extent shoulder belt over passenger's shoulder and across upper torso, and fasten pin connector onto lap belt. Note: Combination lap/shoulder belts serve as both window-side lap belt and shoulder belt. 3. Ensure belts are adjusted as firmly as possible, but consistent with user comfort. Resident #1 Review of the clinical record for Resident #1 revealed the resident was admitted to the facility on [DATE] with a diagnosis of Paraplegia. Review of the Quarterly MDS with and ARD of 09/19/2023 revealed Resident #1 had a BIMS of 15, which indicated the resident was cogitatively intact. Further review of the MDS revealed Resident #1 required a wheelchair for locomotion. Review of the facility's investigation revealed the following: Incident Date: 09/20/2023 Incident Occurred Time: 2:45 p.m. Incident Description: On 09/20/2023, Resident #1 had an appointment at 1:30 p.m. with pain management for her baclofen pump. She was picked up at approximately 2:30 p.m. by van driver in the company van. Van driver secured Resident #1's wheelchair with the straps but failed to put the seat belt around Resident #1 before driving off. When van driver was driving towards the interstate, he approached a red light and had to break hard causing Resident #1 to slide forward out of her wheelchair. Resident #1 landed on her buttock facing the back of the van with her legs in front of her. Van driver pulled over, questioned Resident #1 and asked if she was hurt. Resident #1 stated, I'm fine. I'm not hurting. Van driver and CNA placed Resident #1 back in her wheelchair. Her wheelchair was secured and the seat belt was placed around her. Van driver then stopped to pick up another resident from dialysis and returned to the facility around 4:20 p.m. with both residents. The incident was reported to the Administrator upon their return. The nurse assigned to Resident #1 was instructed by the Administrator to assess her due to the fall. One knee was swollen and Resident #1 was saying her back and leg was hurting. The nurse got an order from her physician and sent her to the emergency room . Review of emergency room Medical Records dated 09/20/2023 revealed Resident #1 was evaluated and found to have left tibia plateau fracture as well as possible left proximal fibular fracture. Resident #1 was treated for pain, had a left long leg splint applied, and was released in stable condition to return to the Nursing Home. On 10/11/2023 at 10:10 a.m., an interview was conducted with Resident #1. Resident #1 stated, on 09/20/2023, she was transported in the facility's transport van. She explained the van driver slammed on the brakes which caused her to fall out of her wheelchair. Resident #1 stated, she was taken to the hospital where it was discovered she had a broken left leg which required a soft cast. On 10/11/2023 at 3:05 p.m., an interview was conducted with S2VD. S2VD stated on 09/20/2023 he loaded Resident #1 into the facility van. S2VD stated he was in a hurry and forgot to secure Resident #1's seat belt. S2VD stated during transport he approached a red light and applied the brakes hard which brought the van to a stop. S2VD stated after he stopped he observed Resident #1 lying on the van floor between the driver and passenger seat. He stated he picked Resident #1 up off the floor, placed her in the seat, then drove her to the facility. On 10/16/2023 at 11:30 a.m., an interview was conducted with S1ADM. S1ADM stated S2VD reported on 09/20/2023 that he stopped at a red light and Resident #1 slid out of her wheelchair. S1ADM stated S2VD stated he got in a hurry and forgot to secure Resident #1's seatbelt. S1ADM confirmed all van drivers should secure wheelchair and resident's seatbelt, shoulder harness and tie downs per facility policy. The facility has implemented the following actions to correct the deficient practice: QA Review revealed: On 09/20/2023 the following plan of correction was put into place to include the following: A. Immediate action taken: Resident #1 was assessed by the nurse. Knee was swollen and she complained of back and leg pain. Nurse sent resident to the ER. Physician and family notified. B. All residents of this facility who were transported by the facility van had the potential to be affected by this deficient practice. C. Actions taken/systems put into place to reduce the risk of future occurrences include: 1. Van drivers were educated on transportation policy and procedure. Completed 09/20/2023 2. Drivers were educated that they must secure the wheelchair in the van and they must use the seat belt around the resident during every transport. Completed 09/20/2023 3. Drivers educated that if a fall occurs while out of the building and in their care, they are to immediately pull over, if driving, call the Administrator or DON for instructions or call 911 for an emergency. Completed 09/20/2023 4. Van drivers were educated on using the safety straps in van to secure the wheelchair and using the seat belt to secure the resident when transporting (Video). Completed 09/20/2023 5. Staff had to demonstrate loading and unloading a wheelchair in the van. Completed 09/20/2023 6. Drivers had a competency completed. Completed 09/20/2023 7. Drivers took education on Assisting residents with transportation, and took a test. D. How corrective actions will be monitored to ensure the practice will not recur: Administrator/designee began monitoring on 09/20/2023 and 09/21/2023 for all residents transported in the van and will continue monitoring 3 x's weekly for one month to ensure drivers are securing the wheelchair using the straps and securing the resident using the seat belt properly and documenting. Results of monitoring will be brought to the QAPI committee. E. Completion date: 09/21/2023 The facility was found to be in compliance as of 09/21/2023. On 10/11/2023 at 2:30 p.m., an observation was made of S3VD, with R6 and R7 loaded in the facility van. Both residents were properly secured and the van driver was knowledgeable and competent in use of safety equipment required in transporting residents. On 10/11/2023 at 3:05 p.m., an interview was conducted with S2VD. He was able to explain the proper way to secure residents for transport following the manufacture's procedures for securing residents. On 10/11/2023 at 3:20 p.m., an interview was conducted with S3VD. He was able to explain the proper way to secure residents for transport following the manufacture's procedures for securing residents.

Based on observations, interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to ensure: 1.) Nurses administered medications as ordered for 7 (#1, #2, #3, #4, #R1, #R2, and #R3) of 8 (#1, #2, #3, #4, # 5, #R1, #R2, and #R3) residents reviewed; 2.) Changes in Respiratory orders were communicated with Respiratory staff for 2 (#3 and #R1) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed; and 3.) Physician's Orders were followed for 4 ( #1, #2, #3, #R2 and #R3) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a dependent resident with an infected Stage 4 Sacral Wound, on 06/13/2023 at 2:30 p.m. when nursing staff failed to communicate a new Physician's Order for intravenous Vancomycin to the pharmacy. From 06/15/2023 through 06/19/2023, Resident #1 missed multiple doses of the intravenous Vancomycin which resulted in further wound infection. On 06/22/2023, S2NP transferred Resident #1 to the emergency room after noting the sacral wound had a foul odor and purulent drainage. Resident #1 returned to the facility on [DATE] with a new Physician's Order to continue intravenous Vancomycin for the Sacral Wound Infection. Nursing staff continued to miss doses of the intravenous Vancomycin as ordered. This deficient practice resulted in an Immediate Jeopardy situation for Resident #3 on 06/26/2023 when respiratory staff failed to administer scheduled breathing treatments twice a day as ordered. Resident #3 had a tracheostomy and was oxygen dependent. On 07/01/2023 and 07/19/2023 nursing staff failed to communicate new orders to respiratory staff. During this time, nursing staff also failed to administer oral, subcutaneous, and IV medications. On 07/15/2023 Resident #3 was found with a faint pulse and with decreased oxygen levels. Resident #3's respirations were labored and shallow. Resident #3 required tracheostomy suctioning, became apneic and required manual breathing. This led to a hospitalization on [DATE] for respiratory distress. This deficient practice resulted in an Immediate Jeopardy situation for Resident #R1 on 07/21/2023, a ventilator dependent resident, when respiratory staff failed to administer scheduled breathing treatments every 8 hours as ordered. Resident #R1 did not receive scheduled breathing treatments after 4:00 p.m. on 07/21/2023 through 07/25/2023, which resulted in the resident experiencing respiratory distress. Resident #R1 was admitted to the hospital on 07/25/2023 with a diagnoses of Sepsis with Severe Septic Shock. Resident #R1 returned to the facility on [DATE] with a Physician's Order for intravenous Cefepime. On 08/02/2023 nursing staff failed to administer the 6:00 a.m. dose of Cefepime to Resident #R1. On 08/02/2023 at 1:00 p.m., an observation was made of Resident #R1 receiving intravenous Meropenem, which was not prescribed to Resident #R1. Resident #R1 was readmitted to the hospital on 08/03/2023 with a diagnoses of Sepsis with Septic Shock, Pneumonia and Hypoxia. S1ADM was notified of the Immediate Jeopardy situation on 08/04/2023 at 7:01 p.m. The Immediate Jeopardy was removed on 08/08/2023 at 2:20 p.m. after the provider presented an acceptable plan of removal. Through observation, interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Plan of Removal: The following actions were taken immediately upon notification on 08/04/2023 to correct noncompliant practices. 1. Medication Administration, Documentation and Translation of orders: a. In-Services were conducted with weekend staff to ensure all nurses were educated on Medication administration, documentation, translation, antibiotic administration, medication availability, pharmacy communication process and communication between Nursing and Respiratory Staff. 100% of nursing staff will be educated by 08/09/2023. b.100% of all residents' medical records were reviewed to ensure accuracy of physician orders. c. Medication pass observations were done on every nurse on every shift during the entire weekend by one of either the DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. Starting 08/04/2023 and all nursing staff will be observed by 08/09/2023. d.100% of all medication carts were looked at and cleaned up by DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. e. Pharmacy communication policy and guidelines were immediately put in place by DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. f. All residents receiving antibiotics were identified and a surveillance spreadsheet was created for direct observation of nurses administering the medication. g. Education was provided to nursing staff in the case that antibiotics were unavailable. Nurses were educated to contact MD, DON and RR Nurses were educated on documenting the unavailability of antibiotic and what steps were taken. h. All residents receiving Respiratory orders were identified and compared to the Respiratory Medication Administration Record. i. Nurses and Respiratory therapists were educated on communicating new Respiratory orders. j. All shifts beginning on 08/04/2023 night shift through 08/07/2023 day shift were educated and observed on medication administration, documentation and translation; antibiotic administration, and communication between nursing and respiratory therapist on new and existing orders. 2. Identification of other residents having the potential to be affected was accomplished by: a. The facility has determined that all residents have the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: The following training began on 08/04/2023 and will be completed by 08/09/2023: a. Immediate complete competency checks on existing nursing staff related to medication administration (see new process attached), documentation, and transcription of orders. Competency checks began on 08/04/2023. All nursing staff to receive competency checks by 08/09/2023. b. New staff and contract staff will be educated on AHT, medication administration processes, documentation, transcription, medication refill process and pharmacy communication. All competencies will be completed before working independently with residents. c. Nurses responsible to send medication refills when indicated. Stickers to be pulled from medication blister packs when indicated and faxed to pharmacy. d. Nurse to initial, time and date fax sheet that was sent to pharmacy. Once faxed, sheet to be put in ADON boxes. Pharmacy delivery receipts to be placed in ADON boxes once medication arrives at facility. e. Power point education to be handed out to entire nursing staff explaining order entering, skin assessments, admission processes, and skilled documentation. A copy of all education was laminated and placed on all med carts. f. Communication between Nursing and Respiratory on any new and existing Respiratory orders by providing new admission or readmission order set to Respiratory Manager or designee. New orders to be copied and handed to Respiratory Manager or designee. Daily monitoring by Respiratory Manager or designee or new orders to be placed in Respiratory box. The following monitoring began on 08/04/2023 and will be completed by 09/22/2023: g. ADONs to review pharmacy delivery receipts daily and compare with faxed medication sheets to ensure all medications have been delivered. Oversight by DON or designee of pharmacy process weekly. h. ADONs or designee to communicate with pharmacy (Monday-Friday) to ensure receipt of faxes. Oversight by DON or designee of pharmacy process weekly. i. Weekly in-services targeted to reorient current nursing staff on Antibiotic availability and administration, AHT, Medication administration, documentation, and transcription to be completed by ADONs and DON. j. All new orders to be pulled and checked by ADON's or designee daily in the morning. k. Monitoring of medication administration, documentation, translation processes as well as physician order review and pharmacy communication as listed above by Regional Corporate Consulting Nurse weekly. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: This plan of correction will be monitored at the monthly Quality Assurance meeting. QA Board to deem effective systems in place by September 22, 2023 via DON report of findings, to assure consistent substantial compliance. This plan of correction will be monitored at the Quality Assurance meeting at least quarterly, optimal monthly at QA progress meetings to ensure consistent substantial compliance. This deficient practice continued at more than minimal harm for the remaining resident identified by the facility as receiving all medications as ordered. Findings: 1.) Review of the facility's Medication Reconciliation policy revealed the following, in part: 2. Resident identifiers will be verified on all medication labels and documents containing medication information to verify the correct person. 5. b. Verify medication labels match physician orders and consider rights of medication administration each time a medication is given. Review of the facility's Medication Reordering policy revealed the following, in part: 2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. Resident #1 A review of the clinical records revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included, Traumatic Spinal Cord Dysfunction, Quadriplegia, Pressure Ulcer of Sacral Region Stage 4, and Cellulitis. A review of Resident #1's Physician Orders dated June 2023 revealed an order for Vancomycin 750mg vial administer Intravenous every twelve hours x 7 days with a start date of 06/13/2023. Further review revealed the physician ordered the last dose of Vancomycin to be given on 06/19/2023. A Review of Resident #1's Medication Administration Record (MAR) dated June 2023 revealed Vancomycin 750 mg IV every 12 hours x7 days was not administered on 06/15/2023 at 9:00 p.m., and the 9:00 a.m. and 9:00 p.m. doses were not administered on 6/17/2023, 06/18/2023, or 06/19/2023. This was indicated on the MAR by either an empty box or circled initials. A review of Resident #1's Nurses' Notes dated June 2023 revealed the following: 06/17/2023 at 8:30 a.m., No Vancomycin available. Called and placed order to pharmacy. Pharmacist will call back regarding Vancomycin. No call back, supervisor aware. 06/19/2023 called and faxed order to pharmacy for IV Vancomycin. 06/20/2023 at 10:00 p.m. Vancomycin not available 06/21/2023 at 9:00 a.m. Vancomycin not available. NP Notified A review of Resident #1's Physician's Progress Notes dated June 2023 revealed the following: 06/13/2023, Ordered Vancomycin 750mg IV every 12 hours x 7 days. 06/23/2023, Wound noted to be deteriorating. IV Vancomycin noted with multiple missed dosing for unknown reason. Patient was referred to long term acute care hospital yesterday for wound needing IV antibiotic treatment, aggressive wound debridement, and Negative Pressure Wound Therapy. A review of Resident #1's clinical lab results revealed the following Vancomycin Trough levels: 06/15/2023- 5.9-low 06/19/2023- <3.5-abnorml 06/21/2023- <3.5-abnormal (Therapeutic values: Trough: 10-20 ug/ml) It is noted the above values are sub therapeutic. A review of Resident #1's Pharmacy Records dated June 2023 revealed the following: 06/19/2023 at 3:21 p.m., Fax received for initial order as follows: (start date 06/13/2023) Vancomycin 750 mg IV every 12 hours x 7 days. Vancomycin trough 30 minutes prior to 4th dose; hold Vancomycin until trough results. A review of the facility's Emergency Transfer Log dated June 2023 revealed Resident #1 was transferred to the hospital on 06/22/2023. A review of Resident #1's Hospital Records from 06/22/2023 revealed Resident #1 arrived at the Emergency Department with a chief complaint of a large sacral wound. Labs were drawn and revealed the following: RBC: 3.24 (low), Hemoglobin: 6.9 (low), Hematocrit 23.8 (low) and Albumin 2.2 (low). Resident #1's labs were significant for severe anemia likely secondary from the bleeding sacral wound. Resident #1 was admitted to the hospital for abnormal labs and received 1 unit of packed red blood cells. Resident #1 received iron while impatient due to iron deficiency anemia. On 06/26/2023, Resident #1 had a wound debridement for the Sacral Decubitus Ulcer, Stage IV. A review of Resident #1's Nurse's Note revealed the resident returned to the facility on [DATE] at 2:00 p.m. A review of Resident #1's Re-admission Physician Orders dated 07/07/2023 revealed the following: Vancomycin 1.25gm/250ml - 0.9% Normal Saline to infuse intravenously every 12 hours for Stage 4 Sacral Wound for 21 days Start Date: 07/07/2023 End Date: 07/29/2023 Cefepime HCL 2 gram vial to infuse intravenously every 12 hours for Cellulitis for 21 days Start Date: 07/07/2023 End Date: 07/29/2023. A Review of Resident #1's Medication Administration Record (MAR) dated July 2023 revealed neither dose of Vancomycin 1.25gm/250ml IV was administered on 07/22/2023, 07/23/2023 and 07/25/2023. Further review revealed Resident #1 did not receive the 9:00 a.m. dose of Vancomycin on 07/24/2023 and 07/26/2023. This was indicated on the MAR by either an empty box or the box indicated not given. Further review of Resident #1's Medication Administration Record (MAR) dated July 2023 revealed Cefepime HCL 2 Grams IV was not administered at 9:00 p.m. on 07/22/2023, 07/23/2023, 07/25/2023 or 07/28/2023. This was indicated on the MAR by either an empty box or the box indicated not given. A review of Resident #1's Nurses' Notes dated July 2023 revealed the following: 07/23/2023 at 12:35 a.m., IV antibiotics not administered, waiting on pharmacy to bring refill, will resume when arrive. 07/24/2023 at 11:20 a.m., Morning IV antibiotics not administered. Awaiting delivery. ADON notified. 07/24/2023 at 11:36 a.m., At start of shift pharmacy called inquiring about IV Vancomycin. Requesting trough levels for 07/21/2023. New orders given to continue current dose and Vancomycin trough on 07/24/2023 and 07/28/2023. Lab results and order faxed to pharmacy. A review of Resident #1's Physician's Progress Notes dated July 2023 revealed the following: 07/27/2023, Discussed with nurse to give Vancomycin as ordered. Apparently Resident #1 has not been given Vancomycin as ordered. Discussed with nurse to follow orders and Vancomycin needs to be given. A review of Resident #1's clinical lab results dated July 2023 revealed the following Vancomycin Trough levels: 07/11/2023- 5.0 ug/mL 07/14/2023- <3.5 ug/mL 07/18/2023- <3.5 ug/mL 07/21/2023- <3.5 ug/mL 07/28/2023- 6.5 ug/mL Target Trough: 10-20 ug/ml It is noted all of the above trough levels were sub therapeutic. A review of Resident #1's Pharmacy Records dated July 2023 revealed the following: 07/07/2023 at 5:18 p.m., Fax received for re-admit physician orders as follows: (start date 07/07/2023 stop date: 07/29/2023) Vancomycin 1.25 gm/250 ml 0.9% NS infuse IV every 12 hours for Stage 4 Sacral Wound for 21 days. 07/07/2023 at 6:22 p.m., 6 doses of Vancomycin sent 07/10/2023 at 2:16 p.m., Nurse said she gave Vancomycin dose at 10:00 a.m. The facility has 5 doses left so that was the only dose given. I faxed the Vancomycin dosing form twice today but she doesn't see the form. Nurse stated labs came back at 3.5 ug/mL. I asked several times to speak with the NP and was told he was busy. Nurse stated they had enough Vancomycin until labs are ordered to be drawn on 07/11/2023. 07/10/2023, 5 remaining doses of Vancomycin in facility at 2:00 p.m. 07/11/2023 at 5:08 p.m., Called and no one answered. Need Vancomycin count. 07/12/2023, 4 remaining doses of Vancomycin in facility at 3:15 p.m., obviously not being given correctly 07/13/2023, 1 dose of Vancomycin sent, 2 doses remaining in facility at 2:44 p.m. 07/14/2023 at 11:43 a.m., Spoke with nurse. Told her we have not been able to get consistent labs or answers since we got this patient and doses are not being given correctly. Labs were not draw again today. I told her we will send enough to get through Monday but if labs aren't drawn on Monday then they will be cutting this patient off unless the doctor and DON are involved. 07/14/2023, 6 doses of Vancomycin sent, 1 dose remaining at 11:35 a.m. 07/17/2023- 0 doses of Vancomycin remains in facility at 1:15 p.m. 07/18/2023 at 12:53 p.m. spoke with S6ADON again about not being able to obtain any information on this patient. S6ADON stated trough was done that morning so I told her to call back with results. 07/18/2023 at 2:23 p.m., Per S6ADON lab results were 3.7 ug/mL, I'm willing to bet they have not been giving the Vancomycin. I have no idea where the Vancomycin is going. I will send 1 dose for tonight and 2 for tomorrow. I will contact the doctor because this patient is not being treated appropriately. 07/18/2023 at 2:37 p.m., 3 doses of Vancomycin, 0 remaining. 07/19/2023 at 7:41 a.m., Spoke with S3DON. I told her we had problems getting the correct information needed. I read her my notes to help her understand the problems we had been having and the lack of care/concerns. I told her we will no longer be dosing for this facility, we will require Dr. to dose form faxed to us. Pharmacy gave specific instructions on what was needed. 07/20/2023 at 11:06 a.m., Spoke with nurse who informed Pharmacy Resident #1 line came out so they were waiting for replacement. They have 1 Vancomycin on hand. Instructed her to follow up with labs. Will send out 1 dose of Vancomycin. Dr. to dose sheet faxed. 07/20/2023, 1 dose of Vancomycin sent 07/21/2023 at 7:27 a.m., Dr. to dose form faxed. 07/21/2023 at 11:15 a.m., Called phone rang off hook. 07/21/2023 at 4:10 pm., No labs yet 07/24/2023 at 8:36 a.m., Spoke with nurse who was looking for Vancomycin. I told her we never received labs or MD orders. I told her we need this. We cannot keep sending Vancomycin without any information. Faxed new dose form with all needed to comment section at 8:39 a.m. 07/24/2023 at 9:28 a.m., Spoke with S2NP and he wanted to find out what was needed and what was going on. I gave him all the information needed. 07/24/2023, 5 doses of Vancomycin sent 07/26/2023 at 2:38 p.m., Called, rang, no answer. 07/26/2023, 6 doses of Vancomycin sent, 1 dose remaining at 3:00 p.m., should have 2 for today On 08/01/2023 at 9:20 a.m., an interview was conducted with S10LPN. She stated when a medication was administered, it was documented on the MAR. She stated if the MAR was left blank then it meant the medication was not administered. On 08/01/2023 at 12:30 p.m., an interview was conducted with S3DON. She stated the nurses were expected to request a medication refill prior to the medication running out. She reviewed Resident #1's MARS of June and July 2023 and confirmed Vancomycin and Cefepime was not administered as ordered and should have been. On 08/01/2023 at 12:45 p.m., an interview was conducted with S2NP. He confirmed he was familiar with Resident #1. He stated Vancomycin was ordered on 06/13/2023 for an infected pressure ulcer. He reported reviewing the Vancomycin trough labs and realized the resident was not receiving the medication because the labs were sub therapeutic and not rising. He stated he notified administration about Resident #1 not receiving the Vancomycin. S2NP stated he remembered in June being contacted by a nurse to clarify to give the last dose of Vancomycin since so many doses had been missed. At that time he gave an order to give the last dose. He stated Resident #1's wound abscessed and he sent Resident #1 to the hospital for higher level of wound treatment. He stated he spoke to the nurses and educated them on the importance of receiving the medication and how they needed to follow the orders to give Vancomycin. He reported the resident retuned to the facility on [DATE] with orders for Vancomycin and Cefepime. He stated Resident #1 had multiple missed doses of Vancomycin in July 2023. He stated the pharmacy wanted the nurses to communicate trough levels via fax prior to the medication being sent. S2NP stated he educated the nursing staff and the administration on the pharmacy's new protocol. He stated the nursing staff did not communicate Resident #1 missed doses of either Vancomycin or Cefepime. On 08/01/2023 at 1:21 p.m., a phone interview was conducted with S8RN. He confirmed working the weekend of 06/18/2023-06/19/2023. He stated a nurse reported Resident #1's Vancomycin was not available for administration. He said he directed the nurse to contact the pharmacy and the provider if she could not reach the pharmacy. He stated he did not know if the nurse contacted the pharmacy or if the medication was received and given. He confirmed he did not follow up with the nurse after she reported the medication as unavailable. On 08/01/2023 at 4:05 p.m., an interview was conducted with S15LPN. She confirmed working on 07/22/2023 and 07/23/2023. She stated she did not administer Resident #1's Vancomycin on either day because the medication was not available. She stated she was not trained on the procedure if a resident was out of medication. On 08/02/2023 at 2:00 p.m., an interview was conducted with S3DON. She stated knew Resident #1 did not receive ordered Vancomycin in June 2023. She stated she in-serviced the floor nurses in June on Antibiotic Administration. She stated the nurses did not know the process for obtaining medications from the pharmacy when a resident was out. She stated if the medication was not available the nurses would not administer it and move on. She stated the nurses would not communicate missing medications with herself or the NP. She stated the in service included education on communicating with the ADON, DON, NP and the process to follow if a medication was not available. She stated on 07/11/2023, she received a call from the pharmacy requesting a trough level for Vancomycin and an order from the provider on the plan of care. She stated she educated and instructed the ADON's to oversee the Vancomycin trough levels and the NP order form. She stated the ADON's were responsible to communicate with the pharmacy and the NP. On 08/02/2023 at 3:30 p.m., a telephone interview was conducted with contracted pharmacist. She stated the first time the pharmacy received an order for Resident #1 to start Vancomycin was on 06/19/2023. She confirmed the pharmacy did not receive an order for Resident #1 on 06/13/2023 and therefore did not send medication prior to 06/19/2023. She stated on 06/19/2023, the pharmacy sent 5 bags of Vancomycin to the facility. She stated on 06/21/2023, the facility requested 2 more bags of Vancomycin because they were out. The pharmacist said she sent 2 bags at that time, but the facility should not have been out of the medication. She stated the nurses reported they were giving the medication as ordered, but the Vancomycin trough levels suggested Resident #1 was not receiving the medication appropriately. She stated she called and communicated the suspected missing doses with S3DON in June 2023. She reported the facility had poor communication with pharmacy and would not provide needed information. She reported in July 2023, the pharmacy had the same issues with the facility and missing doses of medication so she spoke with 3DON again. On 08/03/2023 at 3:11 p.m., an interview was conducted with S5ADON. He stated it was the nurse's responsibility to communicate new medication orders with the pharmacy. If a medication was unavailable, the nurse should communicate with the pharmacy, NP/MD, ADON and DON. He stated the nurses did not report Resident #1 was out of Vancomycin in June or July 2023. He stated the medications should have been administered as ordered. On 08/04/2023 at 10:10 a.m., an interview was conducted with S16LPN. She stated Resident #1 was not getting Vancomycin trough labs drawn so the Pharmacy would not send the Vancomycin in June 2023. She confirmed working on the morning of 06/18/2023. She stated she did not give Resident #1's Vancomycin as ordered because it was not available. She stated she notified S2NP and told him she did not have the medication. She stated she did not notify the Pharmacy. On 08/04/2023 at 10:45 a.m., an interview was conducted with S6ADON. S6ADON confirmed knowing Resident #1 had missed doses of Vancomycin in June 20203. She explained in July 2023, S3DON instructed her to oversee the trough levels and communication with the lab and pharmacy. She stated after receiving trough results from the lab, she would then fax the labs to the pharmacy. She confirmed it was unacceptable that Resident #1 missed intravenous Vancomycin and Cefepime. On 08/02/2023 at 2:00 p.m., an interview was conducted with S3DON. S3DON said if a resident's MAR was not initialed by the nurse, it meant the medication was not given. She also said if the MAR had circled initials, it also meant the medication not given. She reviewed Resident #1's clinical record and confirmed Resident #1 had an order for Vancomycin to start on 06/13/2023. She stated she did not know the resident missed doses of Vancomycin until 06/19/2023. She said the nurses did not know the process to follow if a resident was out of medications, so they did not give it. Resident #2 A review of Resident #2's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Quadriplegia, UTI, and Type 2 Diabetes Mellitus. A review of Resident #2's Physician's Orders dated July 2023 revealed an order dated 07/12/2023 for Meropenem 1 gram IV every 8 hours for 7 days. Diagnosis: UTI. Further review revealed an order for Humalog sliding scale: 0-120: 0 units; 121-150: 2 units; 151-200: 4 units; 201-250: 6 units; 251-300: 9 units; 301-350: 12 units; 351-400: 15 units and call MD. A review of Resident #2's MAR dated July 2023 revealed Meropenem 1 gram IV every 8 hours was documented as not given on 07/14/2023 at 6:00 a.m. or 10:00 p.m., 07/15/2023 at 6:00 a.m. or 10:00 p.m., 07/16/2023 at 6:00 a.m., and 07/18/2023 at 10:00 p.m Further review of Resident #2's July 2023 MAR revealed: 07/14/2023 at 4:30 p.m., Accucheck result of 165 and no documentation of insulin administered. 07/19/2023 at 7:30 a.m., Accucheck result of 135 and no documentation of insulin administered. 07/27/2023 at 4:30 p.m., Accucheck result of 218 and documentation of incorrect insulin dose of 4 units administered. A review of Resident #2's nurses' notes revealed no documentation as to why the resident did not receive Meropenem, the incorrect insulin administrations or if the physician was notified. On 08/02/2023 at 11:18 a.m., an interview was conducted with S3DON. S3DON reviewed Resident #2's July 2023 MAR. She confirmed there were blank boxes on the MAR that correlated with the above dates. She verified the blank boxes on the MAR meant the medication was not given. On 08/02/2023 at 12:10 p.m., an interview was conducted with S2NP. He verified he was not notified that Resident #2 missed doses of intravenous Meropenem in July 2023. He also confirmed he was not aware the resident received incorrect insulin coverage in July 2023. On 08/02/2023 at 1:50 p.m., an interview was conducted with S12LPN. S12LPN reviewed Resident #2's July 2023 MAR. She verified the boxes for administration times on 07/14/2023, 07/15/2023, 7/16/2023 and 07/18/2023were blank. She stated if the boxes on the MAR were blank it meant the medication was not administered. Resident #3 A review of the clinical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses, which included Anoxic Brain Damage, Tracheostomy, Osteomyelitis, Congestive Heart Failure, Pressure Ulcer to Left Buttock, Stage 4, Pressure Ulcer of Sacral Area, Stage 4, and Pressure Ulcer to Right Buttock, Stage 4, Gastrostomy Status, and Chronic Respiratory Failure A review of Resident #3's Physicians Orders for June 2023 revealed the following: 06/26/2023, Meropenem 1gm IV every 8 hours for 26 days; 06/26/2023, Albuterol 0.633 mg/3mL give 3 mL via neb every six hours prn wheezing; 06/26/2023, Budesonide 0.5 mg/2mL give 2 mL via neb BID x14 days; 06/26/2023, Duo-neb 0.5-3mg/3mL give 3 mL via neb every six hours prn wheezing; 06/26/2023, Lasix 40 mg administer one tablet per peg twice a day; and 06/26/2023, Levetiracetam 500 mg administer one tablet per peg twice a day. A review of Resident #3's Medication Administration Record (MAR) for June 2023 revealed Meropenem 1gm IV every 8 hours was not administered on 06/28/2023 at 2:00 p.m.; Lasix 40 mg 1 tablet per peg twice a day was not administered on 06/28/2023 at 6:00 a.m. and 6:00 p.m. and on 06/29/2023 at 6:00 a.m. and Keppra 500mg 1 tablet per peg tube twice a day was not administered on 06/28/2023 at 6:00 a.m. A review of the respiratory therapy documentation for Resident #3 revealed Budesonide 0.5 mg/2mL give 2 mL via nebulizer BID was not administered on 06/26/2023, 06/27/2023, or 06/28/2023. A review of the Transfer Log revealed Resident #3 was transferred to the emergency roiagnom on [DATE] due to a critical H&H. A review of Resident #3's Physicians Orders for July 2023 revealed the following: 07/01/2023, Albuterol-Ipratropium 2.5mg-2.5/3mL give 3mL by neb every six hours; 07/01/2023 and 07/19/2023, Levetiracetam 500mg/5mL administer 5mL per peg twice daily; 07/19/2023, Lasix 40 mg administer one tablet per peg daily; 07/19/2023, Enoxaparin 40 mg administer subcutaneous daily; and 07/19/2023, Duo-neb 2.5-0.5 mg/3 mL give 3mL via neb every six hours A review of Resident #3's Medication Administration Record (MAR) for July 2023 revealed the following: Lasix 40 mg 1 tablet per peg tube twice a day was not administered on 07/01/2023 at 6:00 p.m. or 07/28/2023 at 5:00 a.m.; Levetiracetam 500mg/5mL solution, 5 mL solution per peg tube twice a day was not administered on 07/03/2023 and 07/28/2023 at 6:00 a.m., 07/04/2023, 07/20/2023 and 07/21/2023 at 6:00 p.m. and Enoxaparin 40 mg/0.4mL (0.4 mL=40 mg) into the skin subcutaneous daily was not administered on 07/28/2023 at 6:00 a.m. A review of Resident #3's Nurse's notes dated 07/15/2023 revealed the respiratory therapist alerted the nurse Resident # 3 had oxygen saturations levels of 82%. Resident #3's respirations were very shallow and labored, and pulses were faint. The respiratory therapist began mask bag ventilation. A review of Respiratory flowsheet dated 07/15/2023 revealed at 12:20 p.m. Resident #3 respiratory rate was 23 and had an oxygen saturation level of 90%. The respiratory therapist had suctioned bloody plugs, changed the resident's inner trach cannula, and performed trach care. Resident #3's oxygen saturation decreased to 80% and had become apneic. Artificial manual breathing unit with oxygen was initiated and the resident was suctioned three times. Resident #3 had become apneic again and her oxygen saturation levels decreased to 70%. Resident#3 was bagged until Emergency Medical Services arrived. Resident had no respiratory effort and weak pulse. A review of the respiratory therapy documentation for Resident #3 revealed Albuterol-Ipratropium 2.5mg-2.5/3mL was not administered on 07/01/2023-07/15/2023 A review of the Trans

The facility failed to ensure licensed nurses and other nursing personnel had the knowledge, competencies, and skill sets to provide care and respond to each resident's individualized needs by failing to ensure: 1.) Nurses administered medications as ordered for 7 (#1, #2, #3, #4, #R1, #R2, and #R3) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed; 2.) Changes in Respiratory orders were communicated with Respiratory staff for 2 (#3 and #R1) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed; and 3.) Physician's Orders were followed for 4 ( #1, #2, #3, #R2 and #R3) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a dependent resident with an infected Stage 4 Sacral Wound, on 06/13/2023 at 2:30 p.m. when nursing staff failed to communicate a new Physician's Order for intravenous Vancomycin to the pharmacy. From 06/15/2023 through 06/19/2023, Resident #1 missed multiple doses of the intravenous Vancomycin which resulted in further wound infection. On 06/22/2023, S2NP transferred Resident #1 to the emergency room after noting the sacral wound had a foul odor and purulent drainage. Resident #1 returned to the facility on [DATE] with a new Physician's Order to continue intravenous Vancomycin for the Sacral Wound Infection. Nursing staff continued to miss doses of the intravenous Vancomycin as ordered. This deficient practice resulted in an Immediate Jeopardy situation for Resident #3 on 06/26/2023 when respiratory staff failed to administer scheduled breathing treatments twice a day as ordered. Resident #3 had a tracheostomy and was oxygen dependent. On 07/01/2023 and 07/19/2023 nursing staff failed to communicate new orders to respiratory staff. During this time, nursing staff also failed to administer oral, subcutaneous, and IV medications. On 07/15/2023 Resident #3 was found with a faint pulse and with decreased oxygen levels. Resident #3's respirations were labored and shallow. Resident #3 required tracheostomy suctioning, became apneic and required manual breathing. This led to a hospitalization on [DATE] for respiratory distress. This deficient practice resulted in an Immediate Jeopardy situation for Resident #R1 on 07/21/2023, a ventilator dependent resident, when respiratory staff failed to administer scheduled breathing treatments every 8 hours as ordered. Resident #R1 did not receive scheduled breathing treatments after 4:00 p.m. on 07/21/2023 through 07/25/2023, which resulted in the resident experiencing respiratory distress. Resident #R1 was admitted to the hospital on 07/25/2023 with a diagnoses of Sepsis with Severe Septic Shock. Resident #R1 returned to the facility on [DATE] with a Physician's Order for intravenous Cefepime. On 08/02/2023 nursing staff failed to administer the 6:00 a.m. dose of Cefepime to Resident #R1. On 08/02/2023 at 1:00 p.m., an observation was made of Resident #R1 receiving intravenous Meropenem, which was not prescribed to Resident #R1. Resident #R1 was readmitted to the hospital on 08/03/2023 with a diagnoses of Sepsis with Septic Shock, Pneumonia and Hypoxia. S1ADM was notified of the Immediate Jeopardy situation on 08/04/2023 at 7:01 p.m. The Immediate Jeopardy was removed on 08/08/2023 at 2:20 p.m. when the provider presented an acceptable plan of removal. Through observation, interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Plan of Removal: The following actions were taken immediately upon notification on 08/04/2023 to correct noncompliant practices. a. Medication Administration, Documentation and Translation of orders: b. In-services were conducted with weekend staff to ensure all nurses were educated on medication administration, documentation, translation, antibiotic administration, medication availability, pharmacy communication process and communication between Nursing and Respiratory Staff. c. 100% of all residents' medical records were reviewed to ensure accuracy of physician orders. d. Medication pass observations were done on every nurse on every shift during the entire weekend by one of either the DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. e. 100% of all medication carts were looked at and cleaned up by DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. f. Pharmacy communication policy and guidelines were immediately put in place by DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. g. All residents' receiving antibiotics were identified and a surveillance spreadsheet was created for direct observation of nurses administering the medication. h. Education was provided to nursing staff in the case that antibiotics were unavailable. Nurses were educated to contact MD, DON and RP. Nurses were educated on documenting the unavailability of antibiotic and what steps were taken. i. All residents receiving Respiratory orders were identified and compared to the Respiratory Medication Administration Record. j. Nurses and Respiratory therapists were educated on communicating new Respiratory orders. k. All shifts beginning on 08/04/2023 night shift through 08/07/2023 day shift were educated and observed on medication administration, documentation and translation; antibiotic administration, and communication between nursing and respiratory therapist on new and existing orders. 2.) Identification of other residents having the potential to be affected was accomplished by: a. The facility has determined that all residents have the potential to be affected. 3.)Actions taken/systems put into place to reduce the risk of future occurrence include: The following training began on 08/04/2023 and will be completed by 08/09/2023: a. Immediate complete competency checks on existing nursing staff related to medication administration (see new process attached), documentation, and transcription of orders. b. New staff and contract staff will be educated on AHT, medication administration processes, documentation, transcription, medication refill process and pharmacy communication. All competencies will be completed before working independently with residents. c. Communication between Nursing and Respiratory on any new and existing Respiratory orders by providing new admission or readmission order set to Respiratory Manager or designee. New orders to be copied and handed to Respiratory Manager or designee. Daily monitoring by Respiratory Manager or designee or new orders to be placed in Respiratory box. d. Nurses responsible to send medication refills when indicated. Stickers to be pulled from medication blister packs when indicated and faxed to pharmacy e. Nurse to initial, time and date fax sheet that was sent to pharmacy. Once faxed, sheet to be put in ADON boxes. Pharmacy delivery receipts to be placed in ADON boxes once medication arrives at the facility. f. Power point education to be handed out to entire nursing staff explaining order entering, skin assessments, admission processes, and skilled documentation. A copy of all education will be laminated and placed on all med carts. The The following monitoring began on 08/04/2023 and will be completed by 09/22/2023: a. All nurses will complete an initial medication pass observation, observed by DON or designee. Random medication passes will be performed throughout the quarter. (To continue to be monitored until quarterly QA board deems monitoring has been effective by September 22, 2023). b. For ongoing compliance, the DON or designee will conduct weekly medication cart, EMR and medication storage audits starting weekly x 4, then monthly ongoing for Quality Control and to ensure availability of medications for administration. c. The DON and or designees will also conduct medication administration observations at random, 1 on each shift, weekly then ongoing CQI. d. ADONs to review pharmacy delivery receipts daily and compare with faxed medication sheets to ensure all medications have been delivered. (To continue to be monitored until quarterly QA board deems monitoring has been effective by September 22, 2023. e. ADONs or designee to communicate with pharmacy (Monday-Friday) to ensure receipt of faxes. (To continue to be monitored until quarterly QA board deems monitoring has been effective by September 22, 2023). Oversight by DON or designee of pharmacy process weekly. f. Weekly in-services targeted to reorient current nursing staff on Antibiotic availability and administration, AHT, Medication administration, documentation and transcription to be completed by ADONs and DON. (To continue to be monitored until quarterly QA board deems monitoring has been effective by September 22, 2023. g. All new orders to be pulled and checked by ADON's or designee daily (Monday through Friday) in the morning. Oversight by DON or designee weekly. h. Communication between Nursing and Respiratory on any new and existing Respiratory orders by providing new admission or readmission order set to Respiratory Manager or designee. New orders to be copied and handed to Respiratory Manager or designee. Daily monitoring by Respiratory Manager or designee or new orders to be placed in Respiratory box. i. The Regional Nurse or designee will conduct quarterly checks to determine compliance with the completion of the audits by the DON or designee and the identify trends and areas of continued non-compliance. 4.) 4. How the corrective action(s) will be monitored to ensure the practice will not recur: This This plan of correction will be monitored at the monthly Quality Assurance meeting. QA Board to deem effective systems in place by September 22, 2023 via DON report of findings, to assure consistent substantial compliance. This plan of correction will be monitored at the Quality Assurance meeting at least quarterly, optimal monthly at QA progress to ensure consistent substantial compliance. This deficient practice continued at more than minimal harm for the remaining resident identified by the facility as receiving all medications as ordered. Findings: Review of the facility's Medication Reconciliation policy revealed the following, in part: 2. Resident identifiers will be verified on all medication labels and documents containing medication information to verify the correct person. 5. b. Verify medication labels match physician orders and consider rights of medication administration each time a medication is given. Review of the facility's Medication Reordering policy revealed the following, in part: 2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. Resident #1 A review of the clinical records revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included, Traumatic Spinal Cord Dysfunction, Quadriplegia, Pressure Ulcer of Sacral Region Stage 4, and Cellulitis. A review of Resident #1's Physician Orders dated June 2023 revealed an order for Vancomycin 750mg vial administer Intravenous every twelve hours x 7 days with a start date of 06/13/2023. Further review revealed the physician ordered the last dose of Vancomycin to be given on 06/19/2023. A Review of Resident #1's Medication Administration Record (MAR) dated June 2023 revealed Vancomycin 750 mg IV every 12 hours x7 days was not administered on 06/15/2023 at 9:00 p.m., and the 9:00 a.m. and 9:00 p.m. doses were not administered on 6/17/2023, 06/18/2023, or 06/19/2023. This was indicated on the MAR by either an empty box or circled initials. A review of Resident #1's Nurses' Notes dated June 2023 revealed the following: 06/17/2023 at 8:30 a.m., No Vancomycin available. Called and placed order to pharmacy. Pharmacist will call back regarding Vancomycin. No call back, supervisor aware. 06/19/2023 called and faxed order to pharmacy for IV Vancomycin. 06/20/2023 at 10:00 p.m. Vancomycin not available 06/21/2023 at 9:00 a.m. Vancomycin not available. NP Notified A review of Resident #1's Physician's Progress Notes dated June 2023 revealed the following: 06/13/2023, Ordered Vancomycin 750mg IV every 12 hours x 7 days. 06/23/2023, Wound noted to be deteriorating. IV Vancomycin noted with multiple missed dosing for unknown reason. Patient was referred to long term acute care hospital yesterday for wound needing IV antibiotic treatment, aggressive wound debridement, and Negative Pressure Wound Therapy. A review of Resident #1's clinical lab results revealed the following Vancomycin Trough levels: 06/15/2023- 5.9-low 06/19/2023- <3.5-abnorml 06/21/2023- <3.5-abnormal (Therapeutic values: Trough: 10-20 ug/ml) It is noted the above values are sub therapeutic. A review of Resident #1's Pharmacy Records dated June 2023 revealed the following: 06/19/2023 at 3:21 p.m., Fax received for initial order as follows: (start date 06/13/2023) Vancomycin 750 mg IV every 12 hours x 7 days. Vancomycin trough 30 minutes prior to 4th dose; hold Vancomycin until trough results. A review of the facility's Emergency Transfer Log dated June 2023 revealed Resident #1 was transferred to the hospital on 06/22/2023. A review of Resident #1's Hospital Records from 06/22/2023 revealed Resident #1 arrived at the Emergency Department with a chief complaint of a large sacral wound. Labs were drawn and revealed the following: RBC: 3.24 (low), Hemoglobin: 6.9 (low), Hematocrit 23.8 (low) and Albumin 2.2 (low). Resident #1's labs were significant for severe anemia likely secondary from the bleeding sacral wound. Resident #1 was admitted to the hospital for abnormal labs and received 1 unit of packed red blood cells. Resident #1 received iron while impatient due to iron deficiency anemia. On 06/26/2023, Resident #1 had a wound debridement for the Sacral Decubitus Ulcer, Stage IV. A review of Resident #1's Nurse's Note revealed the resident returned to the facility on [DATE] at 2:00 p.m. A review of Resident #1's Re-admission Physician Orders dated 07/07/2023 revealed the following: Vancomycin 1.25gm/250ml - 0.9% Normal Saline to infuse intravenously every 12 hours for Stage 4 Sacral Wound for 21 days Start Date: 07/07/2023 End Date: 07/29/2023 Cefepime HCL 2 gram vial to infuse intravenously every 12 hours for Cellulitis for 21 days Start Date: 07/07/2023 End Date: 07/29/2023. A Review of Resident #1's Medication Administration Record (MAR) dated July 2023 revealed neither dose of Vancomycin 1.25gm/250ml IV was administered on 07/22/2023, 07/23/2023 and 07/25/2023. Further review revealed Resident #1 did not receive the 9:00 a.m. dose of Vancomycin on 07/24/2023 and 07/26/2023. This was indicated on the MAR by either an empty box or the box indicated not given. Further review of Resident #1's Medication Administration Record (MAR) dated July 2023 revealed Cefepime HCL 2 Grams IV was not administered at 9:00 p.m. on 07/22/2023, 07/23/2023, 07/25/2023 or 07/28/2023. This was indicated on the MAR by either an empty box or the box indicated not given. A review of Resident #1's Nurses' Notes dated July 2023 revealed the following: 07/23/2023 at 12:35 a.m., IV antibiotics not administered, waiting on pharmacy to bring refill, will resume when arrive. 07/24/2023 at 11:20 a.m., Morning IV antibiotics not administered. Awaiting delivery. ADON notified. 07/24/2023 at 11:36 a.m., At start of shift pharmacy called inquiring about IV Vancomycin. Requesting trough levels for 07/21/2023. New orders given to continue current dose and Vancomycin trough on 07/24/2023 and 07/28/2023. Lab results and order faxed to pharmacy. A review of Resident #1's Physician's Progress Notes dated July 2023 revealed the following: 07/27/2023, Discussed with nurse to give Vancomycin as ordered. Apparently Resident #1 has not been given Vancomycin as ordered. Discussed with nurse to follow orders and Vancomycin needs to be given. A review of Resident #1's clinical lab results dated July 2023 revealed the following Vancomycin Trough levels: 07/11/2023- 5.0 ug/mL 07/14/2023- <3.5 ug/mL 07/18/2023- <3.5 ug/mL 07/21/2023- <3.5 ug/mL 07/28/2023- 6.5 ug/mL Target Trough: 10-20 ug/ml It is noted all of the above trough levels were sub therapeutic. A review of Resident #1's Pharmacy Records dated July 2023 revealed the following: 07/07/2023 at 5:18 p.m., Fax received for re-admit physician orders as follows: (start date 07/07/2023 stop date: 07/29/2023) Vancomycin 1.25 gm/250 ml 0.9% NS infuse IV every 12 hours for Stage 4 Sacral Wound for 21 days. 07/07/2023 at 6:22 p.m., 6 doses of Vancomycin sent 07/10/2023 at 2:16 p.m., Nurse said she gave Vancomycin dose at 10:00 a.m. The facility has 5 doses left so that was the only dose given. I faxed the Vancomycin dosing form twice today but she doesn't see the form. Nurse stated labs came back at 3.5 ug/mL. I asked several times to speak with the NP and was told he was busy. Nurse stated they had enough Vancomycin until labs are ordered to be drawn on 07/11/2023. 07/10/2023, 5 remaining doses of Vancomycin in facility at 2:00 p.m. 07/11/2023 at 5:08 p.m., Called and no one answered. Need Vancomycin count. 07/12/2023, 4 remaining doses of Vancomycin in facility at 3:15 p.m., obviously not being given correctly 07/13/2023, 1 dose of Vancomycin sent, 2 doses remaining in facility at 2:44 p.m. 07/14/2023 at 11:43 a.m., Spoke with nurse. Told her we have not been able to get consistent labs or answers since we got this patient and doses are not being given correctly. Labs were not draw again today. I told her we will send enough to get through Monday but if labs aren't drawn on Monday then they will be cutting this patient off unless the doctor and DON are involved. 07/14/2023, 6 doses of Vancomycin sent, 1 dose remaining at 11:35 a.m. 07/17/2023- 0 doses of Vancomycin remains in facility at 1:15 p.m. 07/18/2023 at 12:53 p.m. spoke with S6ADON again about not being able to obtain any information on this patient. S6ADON stated trough was done that morning so I told her to call back with results. 07/18/2023 at 2:23 p.m., Per S6ADON lab results were 3.7 ug/mL, I'm willing to bet they have not been giving the Vancomycin. I have no idea where the Vancomycin is going. I will send 1 dose for tonight and 2 for tomorrow. I will contact the doctor because this patient is not being treated appropriately. 07/18/2023 at 2:37 p.m., 3 doses of Vancomycin, 0 remaining. 07/19/2023 at 7:41 a.m., Spoke with S3DON. I told her we had problems getting the correct information needed. I read her my notes to help her understand the problems we had been having and the lack of care/concerns. I told her we will no longer be dosing for this facility, we will require Dr. to dose form faxed to us. Pharmacy gave specific instructions on what was needed. 07/20/2023 at 11:06 a.m., Spoke with nurse who informed Pharmacy Resident #1 line came out so they were waiting for replacement. They have 1 Vancomycin on hand. Instructed her to follow up with labs. Will send out 1 dose of Vancomycin. Dr. to dose sheet faxed. 07/20/2023, 1 dose of Vancomycin sent 07/21/2023 at 7:27 a.m., Dr. to dose form faxed. 07/21/2023 at 11:15 a.m., Called phone rang off hook. 07/21/2023 at 4:10 pm., No labs yet 07/24/2023 at 8:36 a.m., Spoke with nurse who was looking for Vancomycin. I told her we never received labs or MD orders. I told her we need this. We cannot keep sending Vancomycin without any information. Faxed new dose form with all needed to comment section at 8:39 a.m. 07/24/2023 at 9:28 a.m., Spoke with S2NP and he wanted to find out what was needed and what was going on. I gave him all the information needed. 07/24/2023, 5 doses of Vancomycin sent 07/26/2023 at 2:38 p.m., Called, rang, no answer. 07/26/2023, 6 doses of Vancomycin sent, 1 dose remaining at 3:00 p.m., should have 2 for today On 08/01/2023 at 9:20 a.m., an interview was conducted with S10LPN. She stated when a medication was administered, it was documented on the MAR. She stated if the MAR was left blank then it meant the medication was not administered. On 08/01/2023 at 12:30 p.m., an interview was conducted with S3DON. She stated the nurses were expected to request a medication refill prior to the medication running out. She reviewed Resident #1's MARS of June and July 2023 and confirmed Vancomycin and Cefepime was not administered as ordered and should have been. On 08/01/2023 at 12:45 p.m., an interview was conducted with S2NP. He confirmed he was familiar with Resident #1. He stated Vancomycin was ordered on 06/13/2023 for an infected pressure ulcer. He reported reviewing the Vancomycin trough labs and realized the resident was not receiving the medication because the labs were sub therapeutic and not rising. He stated he notified administration about Resident #1 not receiving the Vancomycin. S2NP stated he remembered in June being contacted by a nurse to clarify to give the last dose of Vancomycin since so many doses had been missed. At that time he gave an order to give the last dose. He stated Resident #1's wound abscessed and he sent Resident #1 to the hospital for higher level of wound treatment. He stated he spoke to the nurses and educated them on the importance of receiving the medication and how they needed to follow the orders to give Vancomycin. He reported the resident retuned to the facility on [DATE] with orders for Vancomycin and Cefepime. He stated Resident #1 had multiple missed doses of Vancomycin in July 2023. He stated the pharmacy wanted the nurses to communicate trough levels via fax prior to the medication being sent. S2NP stated he educated the nursing staff and the administration on the pharmacy's new protocol. He stated the nursing staff did not communicate Resident #1 missed doses of either Vancomycin or Cefepime. On 08/01/2023 at 1:21 p.m., a phone interview was conducted with S8RN. He confirmed working the weekend of 06/18/2023-06/19/2023. He stated a nurse reported Resident #1's Vancomycin was not available for administration. He said he directed the nurse to contact the pharmacy and the provider if she could not reach the pharmacy. He stated he did not know if the nurse contacted the pharmacy or if the medication was received and given. He confirmed he did not follow up with the nurse after she reported the medication as unavailable. On 08/01/2023 at 4:05 p.m., an interview was conducted with S15LPN. She confirmed working on 07/22/2023 and 07/23/2023. She stated she did not administer Resident #1's Vancomycin on either day because the medication was not available. She stated she was not trained on the procedure if a resident was out of medication. On 08/02/2023 at 2:00 p.m., an interview was conducted with S3DON. She stated knew Resident #1 did not receive ordered Vancomycin in June 2023. She stated she in-serviced the floor nurses in June on Antibiotic Administration. She stated the nurses did not know the process for obtaining medications from the pharmacy when a resident was out. She stated if the medication was not available the nurses would not administer it and move on. She stated the nurses would not communicate missing medications with herself or the NP. She stated the in service included education on communicating with the ADON, DON, NP and the process to follow if a medication was not available. She stated on 07/11/2023, she received a call from the pharmacy requesting a trough level for Vancomycin and an order from the provider on the plan of care. She stated she educated and instructed the ADON's to oversee the Vancomycin trough levels and the NP order form. She stated the ADON's were responsible to communicate with the pharmacy and the NP. On 08/02/2023 at 3:30 p.m., a telephone interview was conducted with contracted pharmacist. She stated the first time the pharmacy received an order for Resident #1 to start Vancomycin was on 06/19/2023. She confirmed the pharmacy did not receive an order for Resident #1 on 06/13/2023 and therefore did not send medication prior to 06/19/2023. She stated on 06/19/2023, the pharmacy sent 5 bags of Vancomycin to the facility. She stated on 06/21/2023, the facility requested 2 more bags of Vancomycin because they were out. The pharmacist said she sent 2 bags at that time, but the facility should not have been out of the medication. She stated the nurses reported they were giving the medication as ordered, but the Vancomycin trough levels suggested Resident #1 was not receiving the medication appropriately. She stated she called and communicated the suspected missing doses with S3DON in June 2023. She reported the facility had poor communication with pharmacy and would not provide needed information. She reported in July 2023, the pharmacy had the same issues with the facility and missing doses of medication so she spoke with 3DON again. On 08/03/2023 at 3:11 p.m., an interview was conducted with S5ADON. He stated it was the nurse's responsibility to communicate new medication orders with the pharmacy. If a medication was unavailable, the nurse should communicate with the pharmacy, NP/MD, ADON and DON. He stated the nurses did not report Resident #1 was out of Vancomycin in June or July 2023. He stated the medications should have been administered as ordered. On 08/04/2023 at 10:10 a.m., an interview was conducted with S16LPN. She stated Resident #1 was not getting Vancomycin trough labs drawn so the Pharmacy would not send the Vancomycin in June 2023. She confirmed working on the morning of 06/18/2023. She stated she did not give Resident #1's Vancomycin as ordered because it was not available. She stated she notified S2NP and told him she did not have the medication. She stated she did not notify the Pharmacy. On 08/04/2023 at 10:45 a.m., an interview was conducted with S6ADON. S6ADON confirmed knowing Resident #1 had missed doses of Vancomycin in June 20203. She explained in July 2023, S3DON instructed her to oversee the trough levels and communication with the lab and pharmacy. She stated after receiving trough results from the lab, she would then fax the labs to the pharmacy. She confirmed it was unacceptable that Resident #1 missed intravenous Vancomycin and Cefepime. On 08/02/2023 at 2:00 p.m., an interview was conducted with S3DON. S3DON said if a resident's MAR was not initialed by the nurse, it meant the medication was not given. She also said if the MAR had circled initials, it also meant the medication not given. She reviewed Resident #1's clinical record and confirmed Resident #1 had an order for Vancomycin to start on 06/13/2023. She stated she did not know the resident missed doses of Vancomycin until 06/19/2023. She said the nurses did not know the process to follow if a resident was out of medications, so they did not give it. Resident #2 A review of Resident #2's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Quadriplegia, UTI, and Type 2 Diabetes Mellitus. A review of Resident #2's Physician's Orders dated July 2023 revealed an order dated 07/12/2023 for Meropenem 1 gram IV every 8 hours for 7 days. Diagnosis: UTI. Further review revealed an order for Humalog sliding scale: 0-120: 0 units; 121-150: 2 units; 151-200: 4 units; 201-250: 6 units; 251-300: 9 units; 301-350: 12 units; 351-400: 15 units and call MD. A review of Resident #2's MAR dated July 2023 revealed Meropenem 1 gram IV every 8 hours was documented as not given on 07/14/2023 at 6:00 a.m. or 10:00 p.m., 07/15/2023 at 6:00 a.m. or 10:00 p.m., 07/16/2023 at 6:00 a.m., and 07/18/2023 at 10:00 p.m Further review of Resident #2's July 2023 MAR revealed: 07/14/2023 at 4:30 p.m., Accucheck result of 165 and no documentation of insulin administered. 07/19/2023 at 7:30 a.m., Accucheck result of 135 and no documentation of insulin administered. 07/27/2023 at 4:30 p.m., Accucheck result of 218 and documentation of incorrect insulin dose of 4 units administered. A review of Resident #2's nurses' notes revealed no documentation as to why the resident did not receive Meropenem, the incorrect insulin administrations or if the physician was notified. On 08/02/2023 at 11:18 a.m., an interview was conducted with S3DON. S3DON reviewed Resident #2's July 2023 MAR. She confirmed there were blank boxes on the MAR that correlated with the above dates. She verified the blank boxes on the MAR meant the medication was not given. On 08/02/2023 at 12:10 p.m., an interview was conducted with S2NP. He verified he was not notified that Resident #2 missed doses of intravenous Meropenem in July 2023. He also confirmed he was not aware the resident received incorrect insulin coverage in July 2023. On 08/02/2023 at 1:50 p.m., an interview was conducted with S12LPN. S12LPN reviewed Resident #2's July 2023 MAR. She verified the boxes for administration times on 07/14/2023, 07/15/2023, 7/16/2023 and 07/18/2023were blank. She stated if the boxes on the MAR were blank it meant the medication was not administered. Resident #3 A review of the clinical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses, which included Anoxic Brain Damage, Tracheostomy, Osteomyelitis, Congestive Heart Failure, Pressure Ulcer to Left Buttock, Stage 4, Pressure Ulcer of Sacral Area, Stage 4, and Pressure Ulcer to Right Buttock, Stage 4, Gastrostomy Status, and Chronic Respiratory Failure A review of Resident #3's Physicians Orders for June 2023 revealed the following: 06/26/2023, Meropenem 1gm IV every 8 hours for 26 days; 06/26/2023, Albuterol 0.633 mg/3mL give 3 mL via neb every six hours prn wheezing; 06/26/2023, Budesonide 0.5 mg/2mL give 2 mL via neb BID x14 days; 06/26/2023, Duo-neb 0.5-3mg/3mL give 3 mL via neb every six hours prn wheezing; 06/26/2023, Lasix 40 mg administer one tablet per peg twice a day; and 06/26/2023, Levetiracetam 500 mg administer one tablet per peg twice a day. A review of Resident #3's Medication Administration Record (MAR) for June 2023 revealed Meropenem 1gm IV every 8 hours was not administered on 06/28/2023 at 2:00 p.m.; Lasix 40 mg 1 tablet per peg twice a day was not administered on 06/28/2023 at 6:00 a.m. and 6:00 p.m. and on 06/29/2023 at 6:00 a.m. and Keppra 500mg 1 tablet per peg tube twice a day was not administered on 06/28/2023 at 6:00 a.m. A review of the respiratory therapy documentation for Resident #3 revealed Budesonide 0.5 mg/2mL give 2 mL via nebulizer BID was not administered on 06/26/2023, 06/27/2023, or 06/28/2023. A review of the Transfer Log revealed Resident #3 was transferred to the emergency roiagnom on [DATE] due to a critical H&H. A review of Resident #3's Physicians Orders for [TRUNCATED]

47173 Based on observations, interviews and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to implement a system to provide quality care to meet the needs of each resident. The facility failed to ensure a functional system was in place to acquire, receive, transcribe, and implement accurate physician orders for 7 ( #1,#2,#3,#4, #R1, #R2, #R3) out of 8 ( #1, #2, #3, #4, #5, #R1, #R2, #R3) residents reviewed. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a dependent resident with an infected Stage 4 Sacral Wound, on 06/13/2023 at 2:30 p.m. when nursing staff failed to communicate a new Physician's Order for intravenous Vancomycin to the pharmacy. From 06/15/2023 through 06/19/2023, Resident #1 missed 7 of the 10 doses ordered of intravenous Vancomycin which resulted in further wound infection. On 06/22/2023, S2NP transferred Resident #1 to the emergency room after noting the sacral wound had a foul odor and purulent drainage. Resident #1 returned to the facility on [DATE] with a new Physician's Order to continue intravenous Vancomycin for the Sacral Wound Infection. Nursing staff continued to miss doses of the intravenous Vancomycin as ordered. This deficient practice resulted in an Immediate Jeopardy situation for Resident #3 on 06/26/2023 when respiratory staff failed to administer scheduled breathing treatments twice a day as ordered. Resident #3 had a tracheostomy and was oxygen dependent. On 07/01/2023 and 07/19/2023 nursing staff failed to communicate new orders to respiratory staff. During this time, nursing staff also failed to administer oral, subcutaneous, and IV medications. On 07/15/2023 Resident #3 was found with a faint pulse and with decreased oxygen levels. Resident #3's respirations were labored and shallow. Resident #3 required tracheostomy suctioning, became apneic and required manual breathing. This led to a hospitalization on [DATE] for respiratory distress. This deficient practice resulted in an Immediate Jeopardy situation for Resident #R1 on 07/21/2023, a ventilator dependent resident, when respiratory staff failed to administer scheduled breathing treatments every 8 hours as ordered. Resident #R1 did not receive scheduled breathing treatments after 4:00 p.m. on 07/21/2023 through 07/25/2023, which resulted in the resident experiencing respiratory distress. Resident #R1 was admitted to the hospital on 07/25/2023 with a diagnoses of Sepsis with Severe Septic Shock. Resident #R1 returned to the facility on [DATE] with a Physician's Order for intravenous Cefepime. On 08/02/2023 nursing staff failed to administer the 6:00 a.m. dose of Cefepime to Resident #R1. On 08/02/2023 at 1:00 p.m., an observation was made of Resident #R1 receiving intravenous Meropenem, which was not prescribed to Resident #R1. Resident #R1 was readmitted to the hospital on 08/03/2023 with a diagnoses of Sepsis with Septic Shock, Pneumonia and Hypoxia. S1ADM was notified of the Immediate Jeopardy situation on 08/04/2023 at 7:01 p.m. The Immediate Jeopardy was removed on 08/08/2023 at 2:20 p.m. when the provider presented an acceptable plan of removal. Through observation, interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Plan of removal: The following actions were taken immediately upon notification on 08/04/2023 to correct noncompliant practices. 1.) Medication Administration, Documentation and Translation of orders: In-services were conducted with weekend staff to ensure all nurses were educated on medication administration, documentation, translation, antibiotic administration, medication availability, pharmacy communication process and communication between Nursing and Respiratory Staff. -100% of all residents' medical records were reviewed to ensure accuracy of physician orders. - Medication pass observations were done on every nurse on every shift during the entire weekend by one of either the DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. -100% of all medication carts were looked at and cleaned up by DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. Pharmacy communication policy and guidelines were immediately put in place by DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. -All residents' receiving antibiotics were identified and a surveillance spreadsheet was created for direct observation of nurses administering the medication. -Education was provided to nursing staff in the case that antibiotics were unavailable. Nurses were educated to contact MD, DON and RR Nurses were educated on documenting the unavailability of antibiotic and what steps were taken. All residents receiving Respiratory orders were identified and compared to the Respiratory Medication Administration Record. - Nurses and Respiratory therapists were educated on communicating new Respiratory orders. All shifts beginning on 08/04/2023 night shift through 08/07/2023 day shift were educated and observed on medication administration, documentation and translation; antibiotic administration, and communication between nursing and respiratory therapist on new and existing orders. -All nurses will complete an initial medication pass observation, observed by DON or designee. Random medication passes will be performed throughout the quarter. (To continue to be monitored until QA board deems monitoring has been effective by September 22, 2023). Policies have been reviewed. No changes determined to be necessary. 2.) Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. Actions taken/systems put into place to reduce the risk of future occurrence include: -On 08/04/2023, Administrator and DON were educated by Regional Corporate Consulting Nurse regarding the job duties and responsibilities associated with administering medications as ordered (by mouth, intravenous, respiratory), the 5 Rights to medication administration and medication availability. Completed by 08/04/2023. The following training with nurses and respiratory therapists began on 08/04/2023 and will be completed by 08/09/2023: -Immediate complete competency checks on existing nursing staff related to medication administration (see new process attached), documentation, and transcription of orders. -New staff and contract staff will be educated on AHT, medication administration processes, documentation, transcription, medication refill process and pharmacy communication. All competencies will be completed before working independently with residents. -Communication between Nursing and Respiratory on any new and existing Respiratory orders by providing new admission or readmission order set to Respiratory Manager or designee. New orders to be copied and handed to Respiratory Manager or designee. Daily monitoring by Respiratory Manager or designee or new orders to be placed in Respiratory box. -Nurses responsible to send medication refills when indicated. Stickers to be pulled from medication blister packs when indicated and faxed to pharmacy. -Nurse to initial, time and date fax sheet that was sent to pharmacy. Once faxed, sheet to be put in ADON boxes. Pharmacy delivery receipts to be placed in ADON boxes once medication arrives at facility. -Power point education to be handed out to entire nursing staff explaining order entering, skin assessments, admission processes, and skilled documentation. A copy of all education will be laminated and placed on all med carts. The Administrator will review the implementation of the following beginning on 08/04/2023 and will be completed by 09/22/2023: -All nurses will complete an initial medication pass observation, observed by DON or designee. Random medication passes will be performed throughout the quarter. (To continue to be monitored until quarterly QA board deems monitoring has been effective by September 22, 2023). - For ongoing compliance, the DON or designee will conduct weekly medication cart, EMR and medication storage audits starting weekly x 4, then monthly ongoing for Quality Control and to ensure availability of medications for administration. -The DON and or designees will also conduct medication administration observations at random, 1 on each shift, weekly x 4, then ongoing CQI. -The DON or designee will notify the administrator of the findings of the audit and medication administration observation. -ADONs to review pharmacy delivery receipts daily and compare with faxed medication sheets to ensure all medications have been delivered. (To continue to be monitored until quarterly QA board deems monitoring has been effective by September 22, 2023). -ADONs or designee to communicate with pharmacy (Monday-Friday) to ensure receipt of faxes. (To continue to be monitored until quarterly QA board deems monitoring has been effective by September 22, 2023). Oversight by DON or designee of pharmacy process weekly. -Weekly in-services targeted to reorient current nursing staff on Antibiotic availability and administration, Al-IT, Medication administration, documentation, and transcription to be completed by ADONs and DON. (To continue to be monitored until quarterly QA board deems monitoring has been effective by September 22, 2023). -All new orders to be pulled and checked by ADON's or designee daily (Monday through Friday) in the morning. Oversight by DON or designee weekly. -Communication between Nursing and Respiratory on any new and existing Respiratory orders by providing new admission or readmission order set to Respiratory Manager or designee. New orders to be copied and handed to Respiratory Manager or designee. Daily monitoring by Respiratory Manager or designee or new orders to be placed in Respiratory box. -The Regional Nurse or designee will conduct quarterly checks to determine compliance with the completion of the audits by the DON or designee and to identify trends and areas of continued noncompliance. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: This plan of correction will be monitored at the monthly Quality Assurance meeting. QA Board to deem effective systems in place by September 22, 2023 via DON report of findings, to assure consistent substantial compliance. This plan of correction will be monitored at the Quality Assurance meeting at least quarterly, optimal monthly at QA progress meetings to ensure consistent substantial compliance. This deficient practice continued at more than minimal harm for the remaining residents identified by the facility as receiving medications. Findings: Cross reference: F-726 Cross Reference F-684 On 08/01/2023 at 12:45 p.m., an interview was conducted with S2NP. S2NP stated in June 2023, he was aware Resident #1 was not receiving intravenous Vancomycin as ordered for an infected pressure ulcer. He stated he notified facility's DON about it. He stated Resident #1's wound abscessed and he sent Resident #1 to the hospital for a higher level of wound treatment. S2NP stated Resident #1 returned to the facility on [DATE] with orders for intravenous Vancomycin and Cefepime. He stated after re-admission, the nurses continued to fail to administer IV antibiotics as ordered. On 08/01/2023 at 1:21 p.m., a telephone interview was conducted with S8RN. He stated he was the RN Supervisor on weekends. He stated a nurse had informed him intravenous Vancomycin was not available on the weekend of June18th - June 19th. He stated he did not remember which resident. S8RN sated he instructed the nurse to follow up with the provider and pharmacy. He stated he did not follow up with the nurse to verify the medication was available and administered. On 08/01/2023 at 4:05 p.m., an interview was conducted with S15LPN. She stated she was not trained on the procedure to follow when a resident's medication was unavailable. On 08/02/2023 at 1:00 p.m., an observation of Resident #R1 was performed. S3DON observed the bag of IV medicine hanging and verified the bag of medicine was full and labeled for 6:00 a.m., therefore the resident missed that dose. The label on the bag of IV medicine infusing was observed and had a different resident's name. S3DON confirmed Meropenem was infusing and Resident #R1 was not prescribed Meropenem. She verified Resident #R1 was prescribed Cefepime 2 gm/100 ml IV every 8 hours and confirmed the resident received the wrong medication. On 08/02/2023 at 2:00 p.m., an interview was conducted with S3DON. She stated she was aware Resident #1 did not receive intravenous Vancomycin as ordered in June 2023. She stated the nurses did not know the process for obtaining medications from the pharmacy when medications were unavailable. She stated the nurses had not communicated missing medications to her or the NP. She stated she educated nursing staff in June 2023 on the process for acquiring medications if they were not available. She verified residents were not receiving medications as ordered following her educating staff. On 08/02/2023 at 3:30 p.m., an interview was conducted with the contracted pharmacist. She stated she called S3DON in June 2023 and again in July 2023 to report she suspected IV antibiotics were not being administered as ordered and nursing staff were not communicating the Vancomycin trough levels and NP orders to the pharmacy. On 08/03/2023 at 12:40 p.m., an interview was conducted with S22RT. She confirmed the respiratory department administered all nebulizer treatments. She stated the respiratory department does not have access to electronic medical records. She stated the process should be for the nurses to bring a copy of new orders to the respiratory department so they can be implemented. She confirmed the respiratory department did not receive new orders for Resident #3 on 07/02/2023 for Albuterol-Ipratropium 2.5mg-2.5/3mL or on 07/19/2023 for Duo-neb 2.5-0.5 mg/3mL. She verified if the respiratory department did not receive the orders then the medications were not administered. She confirmed Budesonide 0.5 mg/2mL via nebulizer was not administered to Resident #3 for the p.m. doses on 06/26/2023, 06/27/2023 and 06/28/2023 and could not verify why the doses were missed. On 08/03/2023 at 2:26 p.m., an interview was conducted with S21RTD. She verified Iprat-Albut 0.5-3(2.5) mg/3 ml was not documented as administered for Resident #R3 from 07/21/2023 through 07/25/2023 when the resident was transferred to the hospital. S2RTD reported there were no processes in place to ensure residents received respiratory medications and treatments as ordered. On 08/03/2023 at 3:11 p.m., an interview was conducted with S5ADON. He stated it was the nurse's responsibility to communicate new medication orders with the pharmacy. He stated if a medication was unavailable, the nurse should communicate with the pharmacy, NP/MD, ADON, and DON. He stated medications should have been available and administered as ordered. On 08/04/2023 at 10:10 a.m., an interview was conducted with S16LPN. She stated she did not give Resident #1's intravenous Vancomycin as ordered because it was not available. She stated she did not notify the Pharmacy. 48912

Based on observations, interviews, and record reviews, the facility neglected to provide the treatment and services based on assessments and care planning necessary to attain and maintain physical, mental and psychosocial well-being for 5 (#1, #3, #4, R1, R4) out of a total of 11 (#1, #2, #3, #4, 5, R1, R2, R3, R4, R5, R6) sampled residents reviewed for neglect. The facility failed to ensure: 1. Incontinent care was provided for Resident #1. 2. Wound care was provided for Residents #1, #3, #4, R4 3. Physician's wound care orders were received, transcribed, and implemented for Residents #3, #4, R1, R4 4. Physician's antibiotic orders were administered for Residents #R1. The deficient practice resulted in an immediate jeopardy situation on 10/27/2021 when Resident #1 continued to have increase in deterioration of wounds to right foot. Resident #1 was incontinent with right and left knee contractures. Resident had been observed by staff multiple times with his wound dressing saturated with urine and feces. The physician was contacted on 10/27/2021, and the resident was sent to the hospital. Resident #1 returned to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice resulted in an immediate jeopardy situation for Resident #3 on 11/15/2021 when the resident experienced increased pain to the left foot and purulent drainage from the site of the wound. Resident #3's 11/11/2021 hospital discharge order for a wound vac was not initiated and the wound dressing had not been changed by the facility's staff. The resident was readmitted to the hospital on 11/15/2021. The resident was diagnosed with Ulcer of Left Foot with Necrosis of Muscle. Therefore, the facility failed to implement interventions to ensure resident's with wounds were receiving appropriate care, physicians orders were transcribed and implemented appropriately, nursing staff received training, supervision, and monitoring to ensure incontinent care, and wound needs were met. S2Owner and S3ADM were notified of the Immediate Jeopardy on 12/01/2021 at 8:06 p.m. The Immediate Jeopardy was removed on 12/03/2021 at 6:30 p.m. when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following had been initiated and/or implemented prior to exit. The Immediate Jeopardy Plan of Removal included the following: 1. Corrective actions for alleged deficient practice were accomplished for Resident #1 and Resident #3 by the following: a. The facility entered into contract with a new Medical Director and Nurse Practitioner who specialize in wound care and will provide oversight for management and care of all wounds in the facility on a weekly basis. b. Effective 12/3/2021, a Nursing Assistant Clinical Skills Checklist and Competency Evaluation has been implemented to review vital information, policies, and competencies for all CNAs. All CNAs will complete the Nursing Assistant Clinical Skills Checklist and Competency Evaluation by 12/31/2021. c. On 11/26/2021, a facility-wide audit was conducted for all residents receiving wound care of any type by the facility's nursing management team, which consists of the facility's Wound Care Nurse and an RN. Treatment orders for each wound were re-assessed to ensure that appropriate wound care and treatments were in place. After verification, each resident's Treatment Administration Record (TAR) was audited to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . d. Beginning 11/26/2021, full-body skin audits were conducted on every resident currently in the facility to identify any abnormal conditions. MD was immediately notified as necessary of any significant findings. e. On 11/30/2021, all residents currently receiving wound care of any type were assessed by the facility's Nurse Practitioner, along with the facility's nursing management team for proper identification of wounds. At this time, each existing wound and/or any skin concerns identified were assessed for factors that influenced its development, the potential for development of additional issues, and for deterioration. Evaluations of the skin concerns and/or wounds were performed and documented. Documentation included, at a minimum: location, stage (pressure only), size, exudate if present, type (such as purulent), pain if present, nature and frequency, wound bed, color and type of tissue/character (including evidence of healing or eschar), description of wound edges, and surrounding tissue, as appropriate. f. A re-assessment of resident wounds was conducted by facility RN on 12/02/2021 with no significant findings. g. On 12/01/2021, the facility's Nurse Practitioner trained the DON and Treatment Nurse on proper use of a WoundVac with return demonstration. This in-service included: initial start-up, programming, canister changes, dressing changes (applications of gauze and foam wound dressing sets), advanced controls, alarms, cleaning/maintenance, and storage/care. The DON and Treatment Nurse in-serviced all nurses and CNAs thereafter. h. On 11/26/2021, nursing staff was in-serviced regarding contacting the physician for clarification for new admissions/returns from the hospital. 2. All residents have the potential to be affected by this alleged deficient practice. 3. The measures put into place to prevent this alleged deficient practice from re-occurring: a. The CNA Skills Checklist will be completed upon hire during orientation, and annually thereafter or as needed. b. Each existing pressure ulcer will be assessed, evaluated for characteristics, properly staged, and documented by a facility RN on a weekly basis and as needed. c. Nursing staff will be in-serviced weekly on facility's wound care policy and procedure for 4 weeks then quarterly thereafter. d. If physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If telephone orders are received a 3-copy telephone order slip is filled out. One copy is placed in the medical record temporarily until the original copy is returned by the physician (the original copy is sent to the physician for signature). When the original copy is returned, signed, and dated by the physician, it is placed in the resident's chart, and the other copy in the chart is destroyed. The third copy will be given to data entry or other personnel to update the resident's MAR. i. Each medication order must have a dose, frequency, and route. ii. PRN orders must state the reason for which they are to be used, and if this information is incomplete, it should be corrected by a call to the physician. iii. All physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . iv. The medication order must be written on the patient's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . v. The pharmacy must be notified of new physician orders, and all new medications need to be received by the facility in a timely manner. vi. Once all of the above has been completed, the nurse who received the new physician order(s) must sign, date, and note the time. vii. A designated nurse will review all physician order(s) within 24 hours of transcription to ensure compliance. viii. Admitting RN will review the clinical record for all admits/re-admits for appropriate wound care orders. e. Effective 12/03/2021, a Nurse Skills Review Packet has been implemented to review vital information, policies, and competencies for all facility nurses, which includes a Nurse Competency Medication Pass Observation. The facility's pharmacy consultant group provided a Medication Administration Checklist, Med-Pass Guidelines, and Medications with Shortened Expiration Dates to be added to the Nurse Skills Review Packet. 4. Facility will monitor its performance to ensure sustained compliance by the following: a. The Medical Director and Nurse practitioner began accepting residents and will begin rounding at the facility on 12/06/2021. b. To ensure compliance, a designee will monitor a random sample of employees to ensure proper WoundVac operation. This monitor will be completed 3 times per week for 6 weeks, then monthly thereafter until compliance is achieved. c. Nurse Skills review Packet will be completed upon hire during orientation, and annually thereafter or as needed by the DON or nurse designee. All facility nurses will complete the Nurse Skills Review Packet by 12/31/2021. The immediate Jeopardy was removed on 12/03/2021 at 6:30PM for Resident #1 and Resident #3, and remains as an actual harm for resident #1 and #3. The deficient practice remains as a likelihood for more than minimal harm for the remaining residents identified with wounds in the facility. Findings: Review of the facility's policy entitled Abuse, Neglect, and Misappropriation of Property included, in part: 1. The health care center's leadership will prohibit neglect, mental or physical abuse, including involuntary seclusion and misappropriation of property, of patients/residents from staff or other patients/residents. Resident #1: Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnosis, which included: [CONDITION(S)] Following Cerebral Infarction Right Side Dominant, Blister Left Thigh, Laceration Without Foreign Body of Right Elbow, Unspecified Open Wound Left Lower Leg, and Contracture Right and Left Knee. Review of Resident #1's new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 08/12/2021 - Pressure Ulcer Unstageable Right Great Toe Date 08/18/2021 - Pressure Ulcer Unstageable Right Medial Foot Bunion 09/02/2021 - Pressure Ulcer Stage II Between Right Great toe and 2nd Toe 10/07/2021 - Pressure Ulcer Unstageable Right Bottom Footpad 10/26/2021 - Pressure Ulcer Stage III Right Superior and Inferior Lateral Ankle 10/26/2021 - Pressure Ulcer Unstageable Right Medial Heel 10/26/2021 - Pressure Ulcer Stage III Right Lateral Mid Foot 11/28/2021 - Fluid Filled Blister Left Lateral Thigh Review of the MDS with an ARD of 09/29/2021 revealed Resident #1 had a BIMS of 3, which indicated he was severely cognitively impaired. He was dependent on staff for bed mobility, transferring, and toileting. Resident was always incontinent. He was noted to have 3 Stage III Pressure Ulcers and 3 Unstageable Pressure Ulcers. Review of Resident #1's current Care Plan revealed the following, in part: Resident requires assistance with ADLs secondary to [CONDITION(S)] with right sided weakness, [CONDITION(S)] Resident at risk for pressure ulcers secondary to incontinence episodes, decreased mobility. Keep skin clean and dry; observe skin frequently while rendering care, reporting any red/opened areas promptly, and weekly body audits. Resident has a right medial ankle unstageable 05/28/21 -Turn and reposition resident every 2 hours and PRN. Monitor for s/s of infection. Notify MD immediately if s/s occur. Consult wound care specialist for further evaluation and treatment as appropriate Resident has a left medial shin unstageable. Ensure pillow wedge is between both legs for alleviation of pressure and prevention of skin break down. Reposition resident every 2 hours and as needed. Monitor for s/s of infection. Notify MD if s/s occur. Review of Resident #1's hospital records dated 10/27/2021 revealed, in part: Patient has [CONDITION(S)] from a gangrenous right foot with [CONDITION(S)]. This has been brewing for a while. Patient will likely need an amputation. Assessment of the patients right foot and ankle completed this morning due to patient continues to refuse an amputation, despite being told the dangers of having bone infection in the foot, including spread of infection, loss of limb, and death. At the end of discussion, family decided to proceed with hospice care. Review of Resident #1's treatment nurses notes from 08/12/2021 - 11/29/2021 revealed, in part: 08/12/2021 During wound care treatment noticed resident had an unstageable to his right lateral great toe. Skin is soft and boggy, surrounding skin macerated due to bandage soiling. Scant drainage. MD Notified 08/18/2021 Resident has a right medial foot bunion aspect unstageable small amount of liquefying necrotic tissue. Mild odor noted. Surrounding skin macerated. Bandages applied for wounds soiled with urine. MD Notified 09/02/2021 During wound care treatment noticed resident had a stage 2 to his right foot [CONDITION(S)], area between great toe and first toe scant drainage surrounding skin light pink color. Indention note along front of great toe. 10/07/2021 During wound care treatment noticed resident had an unstageable to his right bottom foot pad. Small amount of liquefying necrotic tissue. Surrounding skin macerated due to soiling of bandages for previous treatment. Dressing becomes soiled with urine and feces seeping around brief. MD Notified. RP Notified. Concerned about resident condition and how he is receiving wounds. 10/26/2021 Resident continues to have dressing soiling to wound sites with urine/feces due to contractures. Deterioration noted to right bottom footpad, strong pungent odor, macerated wound edges, moderate amount of liquefying necrotic tissues. Right foot [CONDITION(S)] between first and second digit beginning to connect with right bottom footpads wound scant drainage, macerated wound edges. Right medial foot bunion aspect skin thinning can feel bone, scant drainage, strong odor, macerated wound edges. Right great toe unstageable, scant drainage, macerated wound edges. Resident has stage 3-noted right lateral mid foot moderate amount of drainage, surrounding skin macerated, strong pungent odor. Unstageable noted right medial heel, moderate liquefying necrotic tissue drainage, macerated wound edges. Stage three right lateral malleolus superior and inferior scant drainage, macerated wound edges. MD, S5ADON, and S4DON notified. 10/28/2021 Late Entry 10/27/2021 Resident continued to have increase in deterioration of wounds to right foot. Wound dressing soiling with urine noted. MD, S4DON, and S5ADON were made aware of deterioration. MD was notified of further deterioration 10/27/2021. New order to have resident sent to ER for further evaluation and treatment. 11/08/2021 Resident was readmitted to facility 11/05/2021. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident returned to facility on hospice. Purulent drainage noted. Loud pungent smell noted to right foot. 11/29/2021 Hospice nurse notified of residents overall decline. Review of Resident #1's Nurses notes from 08/18/2021 - 11/29/2021 revealed, in part: 10/27/2021 6:00 p.m. S13MD called to send resident to hospital to evaluate and treat wounds on bilateral feet and lower legs. At this time resident had 100.0 temperature Blood Pressure 125/82, pulse 105, respirations 18 report called, ambulance called, and family notified. 11/05/2021 Resident returned from hospital via ambulance. S13MD notified. Per hospital report gangrene to right toes, amputation refused 11/16/2021 Resident running low-grade temperature today 99.1 and dark urine noted in catheter bag Review of a text message from S13MD to S4DON, S5ADON, and S6WCN dated 11/25/2021 at 12:11 p.m. revealed, in part: As stated in previous meetings, I am not a wound care physician and will not be writing wound care orders especially on patient's with complex wounds and medical doctor orders. I am not there often enough and I believe that S6WCN is overwhelmed with the amount of patients and level of complex wounds they have. This is why I referred to you Nurse Practitioner almost 2 months ago (October 7, 2021), who is a wound care Nurse Practitioner for assistance in management of these patients. I told S14WCS and everyone that I would not write wound care orders as am not agreeing to be held medical legally responsible for that aspect of the patients care. Most of these patients have complex wounds that need physician or Nurse Practitioner level care on a consistent basis. An interview was conducted on 11/24/2021 at 9:10 a.m. with S6WCN. She stated she has seen decline in Resident #1. She stated when his right foot got worse, she contacted S13MD, and that is whom she gets her wound care orders. She stated she told S5ADON, S4DON, and S10CNASup numerous times and charted this resident was not receiving adequate incontinent care. She stated when she would change his dressings, he would be covered in urine and/or feces, his dressings would be saturated, and the deterioration began. She stated she feels the deterioration started due to the resident's bandages being saturated with urine. When asked about missed wound care, she stated the facility was supposed to have another wound care nurse come in on the weekends she cannot, but that doesn't always happen so wound care gets missed. An interview was conducted on 11/24/2021 at 2:42 p.m. with S21FADM. She stated S13MD tried to get a wound care specialist to come and work at this facility but when she quit, the credentials still had not been verified. An observation was made on 11/29/2021 at 8:40 a.m. of Resident #1. Resident #1 had no response when asked questions. His eyes were slightly open, not blinking, lying still with the head of the bed at 20 degrees, and his mouth open. An interview was conducted on 11/29/2021 at 12:10 p.m. with S31HRN. She stated the hospice care could have sent someone in if wound care was missed had S6WCN or the facility communicated it. She stated it was not communicated. An interview was conducted on 11/30/2021 at 8:56 a.m. with S5ADON. She stated on 11/19/2021, S13MD came into the facility and was asked to sign her orders for wound care, labs, etc. S5ADON stated S13MD refused and told S5ADON she did not feel comfortable signing any orders because she did not specialize in wound care. She stated S13MD had made comments about not being a wound care specialist and not feeling comfortable about giving orders. She stated on 11/23/2021 she called S13MD and she would not give her orders for wound care. An interview was conducted on 11/30/2021 at 10:55 a.m. with S4DON. She stated S6WCN told her on multiple occasions Resident #1 was soiled when they went in to do wound care. She stated she spoke with S10CNASup about making more rounds. She stated she felt his wounds deteriorated due to the bandages being soiled and staying soiled until wound care arrived. She stated she was getting orders from S13MD on treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she made rounds, but she was unsure if the CNAs were actually changing Resident #1. She stated her, S5ADON, and S10CNASup made rounds during the day but the night shift did not have anyone to make rounds on them. She stated there was no way to make sure the night shift was doing what they were supposed to do except for CNAs and nurses having their own accountability. An interview was conducted on 12/01/2021 at 12:30 p.m. with S9WCA. He stated the CNAs were no longer changing Resident #1, and every time he and S6WCN would go into the room Resident #1 was covered in feces and/or urine. He stated he could see his wounds getting worse and worse. He stated S6WCN nurse and himself told S10CNASup, S4DON and S5ADON about Resident #1 not being clean or changed adequately. He stated nothing was done. An interview was conducted on 12/01/2021 at 2:22 p.m. with S13MD. She stated she started working at this facility in April 2021, and thought they had a wound care specialist. She stated she has never physically seen Resident #1's foot in person. She stated she received a text message on 10/27/2021 from S6WCN with a picture of how bad his foot was. She stated there was no way his foot got like that overnight, and she was never contacted about the severity until that day. She stated she referred the facility to a Nurse Practitioner wound care specialist in October 2021, but she was never hired. She stated she told the facility on numerous occasions she was not comfortable writing orders for wound care as that was not her specialty. An interview was conducted on 12/01/2021 at 2:55 p.m. with S1Owner. He stated S13MD spoke to them in regards to hiring a wound care specialist. He stated the facility started the process of credentialing the nurse practitioner she referred, but when it came time for the nurse practitioner to start, she never showed up. He stated S13MD voiced her concerns about not having a certified wound care specialist, which is why he was open to hiring someone. Resident #3: Review of the clinical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses, which included: End Stage [CONDITION(S)] on [CONDITION(S)], [CONDITION(S)] of the Left Foot status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS with an ARD of 10/08/2021 revealed Resident #3 had a BIMS of 14, which indicated he was cognitively intact. Review of Resident #3's current Care Plan revealed the following, in part: I have a left foot amputation. I require nursing staff to monitor for red areas or breaks in skin. Cleanse with wound cleaner, pat dry, apply dry gauze, Kerlix and secure with ace bandage daily. Review of Resident #3's wound care orders revealed the following in part: 10/01/2021 to 10/31/2021 Left foot amputation site: cleanse with wound cleaner, Pat dry, apply dry gauze, Kerlix and secure with ace bandage daily. Noted to be written on Physician Telephone Order sheet with MD name and date. Review of Resident #3's treatment administration record (TAR) for October 2021 revealed on 10/16/2021, 10/17/2021, 10/18/2021, and 10/19/2021 were not initialed, which indicated wound care was not done. Review of Resident #3's wound care notes revealed in part the following: 10/01/2021- Left toes 1-5 digit amputation noted. 11x0.1x0.1, 8 sutures still noted intact. Scant drainage. No pungent odor, no c/o pain or discomfort. Swelling noted. 10/22/2021- Amputation site is open, increase in drainage, pink in color, sutures are intact, embedding. Sent to emergency room for evaluation and suture removal. 10/23/2021- Further evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was sent to a local hospital on 10/22/2021. Resident returned to facility 10/22/2021. Assessment of site, sutures were removed. Small amount of purulent drainage noted. Swelling present. Review of Resident #3's hospital records from 10/22/2021 revealed in part: emergency room MD documented; I did speak with his managing plastic surgery service who recommended removal of visible sutures and outpatient follow up. I do not think antibiotics or emergent surgical intervention this evening is indicated. He is appropriate for close outpatient clinical follow-up. Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #3 nurse's notes revealed the following in part: 11/01/2021 at 12:30 P.M. Nurse called to dining room. Resident stated he was dizzy, upon arrival resident started to lose consciousness. Ambulance called, in route to local emergency room . Review of Resident #3's hospital records from 11/01/2021 to 11/11/2021 revealed in part: History and Physical dated 10/10/2021. Resident #3's incision has dehisced and there is now a deep wound present. Several non-absorbable sutures are also still in the foot. The sutures are not holding together the incision, but rather imbedded within the skin on either side of the incision. Ulcer of left foot with Necrotic tissue, biofilm, slough, necrotic subcutaneous tissue, and necrotic fascia was debrided from the wound base. Post wound measurements were approximately 8 cm in length by 3 cm in width by 1.5 cm in depth. Wound extends to fascia. Wound VAC ordered with twice-weekly dressing changes. Wound Care Notes dated 11/11/2021. Patient is okay to be discharged from a podiatry standpoint with outpatient follow-up, wound clinic, and wound VAC with dressing changes twice weekly. Wound VAC ordered with twice-weekly dressing changes. Negative Pressure Wound Treatment is medically necessary for this patient at this time to achieve acceleration of granulation tissue and wound closure. It is my clinical judgement this cannot be achieved using topical dressing or medications. Plan of Care dated 11/11/2021. Discharge orders faxed via Epic and S18BOM confirmed receipt and cleared Resident #3 for return to the facility. S18BOM confirmed they have a wound vac ready for Resident #3. Review of the Business office emails regarding Resident #3's discharge from the hospital revealed the following: An email was received by S16BOM on 11/10/2021 at 2:16 p.m. Resident #3 is having a wound vac placed today and will be ready for discharge back to your facility tomorrow. Just reaching out to make sure you guys will be able to accept him back tomorrow and make accommodations for the wound vac. Please let me know. The above email was forwarded by S16BOM on 11/10/2021 at 2:48 p.m. to S1owner, S2owner, S4DON, S5ADON, S13MD, and S14WCS. An email was received by S16BOM on 11/11/2021 at 9:14 a.m. I understand everything is set for Resident #3 to come back to you? He has a wound vac. I understand this will be getting removed and you guys will place your own? Review of Resident #3's clinical record revealed he was readmitted to the facility on [DATE] with additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #3's Wound care notes revealed the following, in part: 11/12/2021- Resident returned to facility. Readmit wound assessment. Treatment continues with resident's left foot amputation site, deterioration noted to site. 10.8x2.5x1.5 granulation noted with islands of epithelial tissue noted in between, 25% slough noted to wound bed. Moderate amount of drainage. Surrounding skin pink in color. Mild pungent odor noted. Resident denies pain and discomfort to site. Resident was treated with a wound vac while in hospital. Wound vac orders d/c'd upon discharge. New wet to dry order to cleanse with wound cleaner pat dry apply NS soaked gauze cover with ABD pad secure with Kerlix. Treatment administered resident tolerated well. Review of Resident #3's wound care orders revealed the following in part: 11/12/2021 Left foot amputation site, cleanse with wound cleaner, pat dry and apply normal saline soaked gauze, cover with ABD pad, secure with Kerlix every day. Order was handwritten on an order sheet. There was no MD name, date and time of order received. Review of Resident #3's treatment administration record (TAR) for November 2021 revealed on 11/13/2021 and 11/14/2021 the TAR was not initialed, which indicated wound care was not done. Review of Resident #3 nurse's notes revealed the following in part: 11/15/2021 at 7:00 a.m. During report, Resident #3 requested to go to the hospital. Ambulance notified and in route to local emergency room . Review of Resident #3's hospital records from 11/15/2021 revealed in part: History and Physical dated 11/15/2021: Resident #3 presented to local hospital on 11/15/2021 with a primary complaint of Abdominal Pain (2AM) and Foot Pain (Left). Patient tells me since he was discharged 4 days ago, a wound VAC was not placed at the nursing home as ordered, no wound dressing was changed as his wound dressing still has the date he was discharged from the hospital. Patient looks unkempt and has purulent drainage from the site of wound, which was not changed at the nursing home; he also has foul-smelling discharge and [CONDITION(S)] around his groin area and underneath his abdominal folds. An interview was conducted on 11/22/2021 at 11:42 a.m. with S6WCN. She said Resident #3 was admitted on [DATE]. She said for post op surgical residents, sutures would be removed after 7-14 days. She said S19MR would make the follow-up appointments. She said if there were no orders at admit she would be responsible for getting orders from the attending physician for suture removal and informing S19MR to schedule an appointment. On 10/22/2021, she stated she noticed Resident #3 had sutures embedded in the skin with swelling to his left foot. She stated she contacted S13MD and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said Resident #3 returned the same day on 10/22/2021. She said she thinks the sutures could have come out sooner. On 11/01/2021, Resident #3 was sent to the ER due to [CONDITION(S)] episodes. Resident #3 returned to the facility on [DATE]. She confirmed she received the email with wound vac request for discharge for Resident #3 but it was never placed on the wound. On 11/11/2021, she received a verbal report from the discharging nurse at the local hospital the wound vac was discontinued and wound care would be wet to dry dressing changes daily. On Friday, 11/12/2021, she reviewed discharge papers from the local hospital and did not find any wound vac or wound care orders. She confirmed she did not call S13MD or the local hospital for order clarification and transcribed the wet to dry instructions she received in report as an order. She confirmed she completed a wet to dry dressing change on 11/12/2021. She confirmed she did not complete wound care on 11/13/2021 and 11/14/2021. She stated the nurse assigned to Resident #3 would complete wound care when she was not there. She was not aware if the weekend nurses knew she was not working that weekend. An interview was conducted on 11/22/2021 at 9:11 a.m. with S20LPN. She confirmed she worked on 11/13/2021 and was assigned to Resident #3. She confirmed on 11/13/2021 she did not do wound care. She said the wound care nurse comes in on the weekend and takes care of the residents. An interview was completed with S22HMD on 11/22/2021 at 10:11 a.m. She confirmed the local hospital and the facility-coordinated care for Resident #3 to have a wound vac placed on his Left foot. She confirmed when Resident #3 presented to the emergency roiagnom on [DATE], he did not have a wound vac in place and his dressing was dated 11/11/2021. An interview was conducted on 11/23/2021 at 12:00 p.m. with S18BOM. She said on 10/14/2021, S13MD requested an NP for wound care. She said the NP request was brought to the attention of S21FADM. She said she was unsure if S1Owner and S2Owner were aware of the request and was unsure what happened after S21FADM resigned. She said on 11/10/2021, she received an email from the local hospital informing the facility, Resident #3 would need a wound vac. She said she forwarded the email to S4DON, S5ADON, S6WCN, S14WCS, S13MD, S1Owner, and S2Owner. She said on 11/11/2021, she informed the Case Manager at the hospital that the facility had the wound vac and was ready for Resident #3. She said she received an email on 11/11/2021 at 9:14 a.m. which confirmed the hospital would remove the wound vac prior to discharge and confirmed the facility would apply their own wound vac at admit. She confirmed she did not forward this email to nursing or administration. An interview was conducted on 11/23/2021 at 12:30 p.m. with S13MD. On 10/22/2021, she stated S6WCN reported Resident #3 had sutures embedded in the skin with swelling to his left foot. She stated she provided an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she was not made aware of the resident being sent out to the hospital on 11/01/2021 or returning to the facility on [DATE]. She said she shou

Based on record reviews and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 5 (#1, #3, #4, #R1, and #R4) out of a total of 11 (#1, #2, #3, #4, #5, #R1, #R2, #R3, #R4,#R5, and #R6) sampled residents reviewed. The facility failed to ensure: 1. Administrative supervision was provided to continue all administrative duties from 11/15/2021 to 11/28/2021 when S21FADM no longer worked as an administrator at this facility; 2. A plan of action was in place to ensure wound care treatments and orders were administered appropriately to residents by a physician after S13MD stated she would no longer provide wound care services; 3. Nursing staff received training, were determined competent, and were monitored for implementation of resident direct care needs and wound care services to ensure quality of care was provided to residents with wounds, Wound VACs, incontinent care needs, and medication administration; 4. A functional system was in place to verify, receive, transcribe, and implement accurate physician orders; 5. Facility policies were developed and/or implemented for Neglect, Physician Services, Nursing Competencies, and QAPI; and 6. The QAPI committee identified and attempted to correct identified deficiencies. The deficient practice resulted in an immediate jeopardy situation on 10/27/2021 when Resident #1 continued to have increase in deterioration of wounds to right foot. Resident #1 was incontinent with right and left knee contractures. Resident had been observed by staff multiple times with his wound dressing saturated with urine and feces. The physician was contacted on 10/27/2021, and the resident was sent to the hospital. Resident #1 returned to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice resulted in an immediate jeopardy situation for Resident #3 on 11/15/2021 when the resident experienced increased pain to the left foot and purulent drainage from the site of the wound. Resident #3's 11/11/2021 hospital discharge order for a wound vac was not initiated and the wound dressing had not been changed by the facility's staff. The resident was readmitted to the hospital on 11/15/2021. The resident was diagnosed with Ulcer of Left Foot with Necrosis of Muscle. S2Owner and S3ADM were notified of the Immediate Jeopardy on 12/01/2021 at 8:06 p.m. Through observations, interviews and record reviews, the surveyors confirmed the following had been initiated and/or implemented prior to exit. The Immediate Jeopardy Plan of removal included: 1. Corrective actions for alleged deficient practice were accomplished for Resident #1 and Resident #3 by the following: a. The facility then entered into contract with a new Medical Director and Nurse Practitioner who specialize in wound care and will provide oversight for management and care of all wounds in the facility on a weekly basis. The Medical Director and Nurse practitioner began accepting residents and will begin rounding at the facility on 12/06/2021. b. On 11/26/2021, a facility-wide audit was conducted for all residents receiving wound care of any type by the facility's nursing management team, which consists of the facility's Wound Care Nurse and an RN. Treatment orders for each wound were re-assessed to ensure that appropriate wound care and treatments were in place. After verification, each resident's Treatment Administration Record (TAR) was audited to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 11/30/2021, all residents currently receiving wound care of any type were assessed by the facility's Nurse Practitioner, along with the facility's nursing management team for proper identification of wounds. At this time, each existing wound and/or any skin concerns identified were assessed for factors that influenced its development, the potential for development of additional issues, and for deterioration. Evaluations of the skin concerns and/or wounds were performed and documented. Documentation included, at a minimum: location, stage (pressure only), size, exudate if present, type (such as purulent), pain if present, nature and frequency, wound bed, color and type of tissue/character (including evidence of healing or eschar), description of wound edges, and surrounding tissue, as appropriate. d. On 12/01/2021, the facility's Nurse Practitioner trained the DON and Treatment Nurse on proper use of a WoundVac with return demonstration. This in-service included: initial start-up, programming, canister changes, dressing changes (applications of gauze and foam wound dressing sets), advanced controls, alarms, cleaning/maintenance, and storage/care. The DON and Treatment Nurse in-serviced all nurses and CNAs thereafter. e. On 11/26/2021, nursing staff was in-serviced regarding contacting the physician for clarification for new admissions/returns from the hospital. f. As of 12/03/2021, the facility-hired consultants are in the process of reviewing and revising all the facility's current Policies and Procedures. Please take into consideration that along with current survey and processes in review, this will take some time. g. The facility's previous DON was terminated effective 12/01/2021 and an Interim DON has been appointed to resume the responsibilities of the nursing department. The Interim DON has been trained, in-serviced, and directly involved with all staff training and education. 2. All residents have the potential to be affected by this alleged deficient practice. 3. The measures put into place to prevent this alleged deficient practice from re-occurring: a. Each existing pressure ulcer will be assessed, evaluated for characteristics, properly staged, and documented by a facility RN on a weekly basis and as needed. b. Nursing staff will be in-serviced weekly on facility's wound care policy and procedure for 4 weeks then quarterly thereafter. c. On 12/03/2021, facility implemented a weekly, monthly, and quarterly Tracking/Trending Log of nursing programs, to include wound management, infection control, etc. This will allow for identification of any trends as well as prompt implementation of an appropriate plan of action to correct any deficient practices found. d. Every departmental concern within the last quarter will be discussed, as a team, along with solutions. Issues from the previous quarter will also be briefly discussed, especially if these issues have not been resolved. All concerns and solutions for each individual department will be documented. 4. Facility will monitor its performance to ensure sustained compliance by the following: a. To ensure compliance, a designee will monitor a random sample of employees to ensure proper WoundVac operation. This monitor will be completed 3 times per week for 6 weeks, then monthly thereafter until compliance is achieved. b. Effective 12/03/2021, a Nursing Assistant Clinical Skills Checklist and Competency Evaluation has been implemented to review vital information, policies, and competencies for all CNAs. This CNA Skills Checklist will be completed upon hire during orientation, and annually thereafter or as needed. All CNAs will complete the Nursing Assistant Clinical Skills Checklist and Competency Evaluation by 12/31/2021. c. Effective 12/03/2021, a Nurse Skills Review Packet has been implemented to review vital information, policies, and competencies for all facility nurses, which includes a Nurse Competency Medication Pass Observation. PCSA, the facility's pharmacy consultant group, provided a Medication Administration Checklist, Med-Pass Guidelines, and Medications with Shortened Expiration Dates to be added to the Nurse Skills Review Packet. This Nurse Skills review Packet will be completed upon hire during orientation, and annually thereafter or as needed by the DON or nurse designee. All facility nurses will complete the Nurse Skills Review Packet by 12/31/2021. d. A Quarterly Quality Assurance meeting with all facility Department Heads, including the facility's Medical Director, has been implemented effective 12/03/2021. Every Department Head, including the Medical Director, must sign attendance sheet. e. Administrator and DON will be in-serviced by facility-hired consultants on the new QAPI Committee processes and importance of compliance on 12/03/2021. The DON will monitor compliance of the Tracking/Trending Log and QAPI. The Administrator will review all QAPIs initiated by facility, make changes as needed, and log for compliance. Administrator will continue to ensure compliance with on-going monitoring. f. A QAPI for the committee will be conducted beginning with the findings of this survey and every 3 months thereafter. The immediate Jeopardy was removed on 12/03/2021 at 6:30PM for Resident #1 and Resident #3, and remains as an actual harm for resident #1 and #3. The deficient practice remains as a likelihood for more than minimal harm for the remaining residents identified with wounds in the facility. Findings: Cross Reference F600 Cross Reference F684 Cross Reference F726 Cross Reference F835 Cross Reference: F867 On 11/23/2021 at 4:15 p.m., an interview was conducted with S4DON. She stated the facility did not have an effective process in place to ensure physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said, due to a shortage in nursing staff the facility no longer had routine charge nurses on the shifts to assist with order transcription and implementation. She stated the shortage leaves a lot of room for error and it was impossible to track everything. She stated she tried to check orders here and there when she could, but she was not able to ensure all orders were accurate and implemented. She said she had no clue if any residents in the facility had orders that needed clarification or if all orders were implemented. S4DON confirmed the process for acquiring, transcribing, and implementing accurate physicians orders for the facility residents was not effective and had not been effective since her start date of September 2021. She further explained the facility did not have enough nursing staff to ensure wound care was completed as ordered for the residents. She said the facility did not have enough staff to provide care for residents with a Wound VAC and confirmed the nursing staff had not been educated on Wound VAC's. She stated the facility did not have a system in place for new admissions or transfer notifications. She stated if the resident was readmitted , the floor nurse should report to her and she would notify MD if they had not. She stated if orders needed to be clarified for new admissions or readmits, the charge nurse would perform those duties. She stated currently, the facility did not have a charge nurse in place to perform those duties. She was asked if there was a system in place to verify orders and she stated, No, there was no system in place to review and verify transcribed orders. She further confirmed there was no system in place to ensure the physician was notified of a new admission or readmission or a change in the residents condition. She confirmed knowing the facility had quality deficiencies in the areas of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She further confirmed there were no active QA's at this time. An interview was conducted on 11/23/2021 at 4:12 p.m. with S4DON. She said typically the charge nurse clarified orders but currently they do not have a charge nurse. She stated if there were no orders for wound care from the hospital, the nurse would need to contact the attending MD for a verbal order and document the MD name with the date and time the order was received. She stated there was not a current system in place to verify physicians were notified of new or re-admits, notification of transfers, orders transcribed, or verifying orders correctly. On 11/24/2021 at 1:20 p.m., an interview was conducted with S23ED. She confirmed she was responsible for training the nursing staff and was employed by the facility in August 2021. She stated no training needs were brought to her attention by any of the facility staff. She denied being responsible for monitoring the staff to identify training needs or ensure competency. She confirmed she had not provided training to nursing staff on Wound VAC's, wound treatment, incontinent care, medication administration, or physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A telephone interview was conducted on 11/24/2021 at 2:39 p.m. with S21FADM. She stated she was the former administrator, her last physical day to administer the facility was 11/02/2021. She said S13MD expressed concerns with wound care in the facility and requested for a wound care specialist NP to assist with assessing and ordering treatments for residents with wounds. She stated she provided contact information for an NP that may be able to assist to S1Owner and S2Owner, but she had not verified the credentials of the NP. An interview was conducted on 11/24/2021 at 2:30 p.m. with S1Owner. He said the former administrator was doing QAPI but since her last day in the facility on 11/02/2021 QAPI had not been done. He stated a new administrator, S3ADM, start date would be 11/29/2021. An interview was conducted on 11/29/2021 at 11:37 a.m. with S4DON. She stated if there was a change in condition or decline of a resident, she should be notified. She stated if a resident was unresponsive, a medication should not be given by mouth due to choking hazards. She stated she had not been informed of S11LPN administering any medications to Resident #1 while unresponsive, the head of the bed should have never been below 30 degrees, and she was not informed of any change in Resident #1. A Review of the facility's policies and procedures revealed the following Abuse Neglect and Misappropriation of Property Policy dated 12/2006 Abuse Neglect and Misappropriation of Property Policy did not include the following components: Screening, Training, Investigation, Protection and Reporting/Response. An interview was conducted on 11/30/2021 at 8:56 a.m. with S4DON and S5ADON. Both stated all the policies the facility had currently were in a binder. They both confirmed that most of the policies were not updated, and/or they did not have one. They stated they are making a list of all of the policies the surveyors are asking for so that they can update their binder. An interview was conducted on 11/30/2021 at 10:55 a.m. with S4DON. She stated S6WCN told her on multiple occasions Resident #1 was soiled when they went in to do wound care. She stated she spoke with S10CNASup about making more rounds. She stated she felt his wounds deteriorated due to the bandages being soiled and staying soiled until wound care arrived. On 12/01/2021 at 3:20 p.m., an interview was conducted with S2Owner. She stated S21FADM was responsible for QA prior to leaving the facility on 11/15/2021. S2Owner explained she could not locate any documentation of QAPI records for the facility. She said she did not know what the process was for tracking, identifying issues, or monitoring effectiveness of identified quality deficiencies. She stated she did not know if S21FADM was doing that. She confirmed there was no documentation showing QA of any quality issues at the facility. An interview was conducted on 12/01/2021 at 4:42 p.m. with S2Owner. She stated she was aware of S11LPN administering medication to Resident #1. She stated she was aware there were issues that were presented when S15PC came in September, October, and November for the facility's observations. She stated the facility was working with S11LPN. S2Owner stated S11LPN attended an in-service on 11/17/2021 with the other nurses about competency, which covered Medication and cart security, Infection Control Procedures, Medication Administration, Medication Documentation, Medication Refusal, Medication Administered with Enteral Formulas, Resident Assessment, and Medication Errors. She stated that was the only training she had.

Based on observations, interviews and record reviews, the facility failed to ensure resident's received treatment and care based on the comprehensive assessment in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 (#1, #3) of 11 (#1, #2, #3, #4, #5, R1, R2, R3, R4, R5, R6) residents reviewed. The facility further failed to ensure wound care treatment and services were provided for 3(#1 #3, #R1) of 11(#1, #2, #3, #4, #5, R1, R2, R3, R4, R5, R6) residents reviewed. The deficient practice resulted in an immediate jeopardy situation on 10/27/2021 when Resident #1 continued to have increase in deterioration of wounds to right foot. Resident #1 was incontinent with right and left knee contractures. Resident had been observed by staff multiple times with his wound dressing saturated with urine and feces. The physician was contacted on 10/27/2021, and the resident was sent to the hospital. Resident #1 returned to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice resulted in an immediate jeopardy situation for Resident #3 on 11/15/2021 when the resident experienced increased pain to the left foot and purulent drainage from the site of the wound. Resident #3's 11/11/2021 hospital discharge order for a wound vac was not initiated and the wound dressing had not been changed by the facility's staff. The resident was readmitted to the hospital on 11/15/2021. The resident was diagnosed with Ulcer of Left Foot with Necrosis of Muscle. S1Owner was notified of the Immediate Jeopardy on 11/24/2021 at 8:36 p.m. The Immediate Jeopardy was removed on 12/03/2021 at 6:30 p.m. when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following had been implemented prior to exit. The Immediate Jeopardy Plan of Removal included: 1. Corrective actions for the alleged deficient practice were accomplished for Resident #1, Resident #3 and R1 by the following: a. On 11/26/2021, a facility-wide audit was conducted for all residents receiving wound care of any type by the facility's nursing management team, which consists of the facility's Wound Care Nurse and an RN. Treatment orders for each wound were re-assessed to ensure that appropriate wound care and treatments were in place. After verification, each resident's Treatment Administration Record (TAR) was audited to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. Beginning 11/26/2021, full-body skin audits were conducted on every resident currently in the facility to identify any abnormal conditions. MD was immediately notified as necessary of any significant findings. c. On 11/30/2021, all residents currently receiving wound care of any type were assessed by the facility's Nurse Practitioner, along with the facility's nursing management team for proper identification of wounds. At this time, each existing wound and/or any skin concerns identified were assessed for factors that influenced its development, the potential for development of additional issues, and for deterioration. Evaluations of the skin concerns and/or wounds were performed and documented. Documentation included, at a minimum: location, stage (pressure only), size, exudate if present, type (such as purulent), pain if present, nature and frequency, wound bed, color and type of tissue/character (including evidence of healing or eschar), description of wound edges, and surrounding tissue, as appropriate. Each existing pressure ulcer will be assessed, evaluated for characteristics, properly staged, and documented by a facility RN on a weekly basis and as needed. d. A re-assessment of resident wounds was conducted by facility RN on 12/02/2021 with no significant findings. e. On 12/02/2021, the facility's Nurse Practitioner trained the DON and Treatment Nurse on proper use of a Wound Vac with return demonstration. This in-service included: initial start-up, programming, canister changes, dressing changes (applications of gauze and foam wound dressing sets), advanced controls, alarms, cleaning/maintenance, and storage/care. The DON and Treatment Nurse in-serviced all nurses and CNAs thereafter. f. On 11/26/2021, nursing staff was in-serviced regarding contacting the physician for clarification for new admissions/returns from the hospital. g. If physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If telephone orders are received a 3-copy telephone order slip is filled out. One copy is placed in the medical record temporarily until the original copy is returned by the physician (the original copy is sent to the physician for signature). When the original copy is returned, signed, and dated by the physician, it is placed in the resident's chart, and the other copy in the chart is destroyed. The third copy will be given to data entry or other personnel to update the resident's MAR. i. Each medication order must have a dose, frequency, and route. ii. PRN orders must state the reason for which they are to be used, and if this information is incomplete, it should be corrected by a call to the physician. iii. All physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . iv. The medication order must be written on the patient's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . v. The pharmacy must be notified of new physician orders, and all new medications need to be received by the facility in a timely manner. vi. Once all of the above has been completed, the nurse who received the new physician order(s) must sign, date, and note the time. vii. A designated nurse will review all physician order(s) within 24 hours of transcription to ensure compliance. viii. Admitting RN will review the clinical record for all admits/re-admits for appropriate wound care orders. 2. All residents have the potential to be affected by this alleged deficient practice 3. The measures put into place to prevent this alleged deficient practice from re-occurring a. Nursing staff will be in-serviced weekly on facility's wound care policy and procedure for 4 weeks then quarterly thereafter. 4. Facility will monitor its performance to ensure sustained compliance by the following: a. To ensure compliance, a designee will monitor a random sample of employees to ensure proper Wound Vac operation. This monitor will be completed 3 times per week for 6 weeks, then monthly thereafter until compliance is achieved. The immediate Jeopardy was removed on 12/03/2021 at 6:30PM for Resident #1 and Resident #3, and remains as an actual harm for resident #1 and #3. The deficient practice remains as a likelihood for more than minimal harm for the remaining residents identified with wounds in the facility. Findings: Cross Reference: F600, F726, F865, F835 Subject: Orders Medication/Treatment Standard: 1. The licensed nurse will receive and transcribe the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The licensed nursing staff will provide patients/residents with medications and treatment as ordered by his or her physician. Practice Guidelines: Equipment: a. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] b. Telephone Order Form c. Physician's Monthly Order Form 1. Specific medications or treatment supplies are ordered from the pharmacy by telephone, copy of order sheet, fax, or an established system with pharmacy provider. The order must be communicated in a written manner. 2. The licensed nurse clarifies all orders that may lead to an administration error. 3. Transcribe the order onto the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Sign off on the original order with full signature in the appropriate box or bracket order and write Noted, signature, and date. 5. The appropriate nurse is notified of new orders. Subject: MD Order Transcription Intent: It is the policy of the facility to provide a care and services related to MD orders, according to state and federal regulations. Procedure: 1. The facility will have physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The admitting nurse will call the attending physician and clarify all orders on admission. 3. The admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnosis, which included: [CONDITION(S)] Following Cerebral Infarction Right Side Dominant, Blister Left Thigh, Laceration Without Foreign Body of Right Elbow, Unspecified Open Wound Left Lower Leg, and Contracture Right and Left Knee. Review of the MDS with an ARD of 09/29/2021 revealed Resident #1 had a BIMS of 3, which indicated he was severely cognitively impaired. He was dependent on staff for bed mobility, transferring, and toileting. Resident was always incontinent. He was noted to have 3 Stage III Pressure Ulcers and 3 Unstageable Pressure Ulcers. Review of Resident #1's current Care Plan revealed the following, in part: Requires assistance with ADLs secondary to [CONDITION(S)] with right sided weakness, [CONDITION(S)]. Assist resident with clean clothes daily and prn soilage. Q2 hour rounds assisting with turning, assessing for needs. Resident at risk for pressure ulcers secondary to incontinence episodes, decreased mobility. Keep skin clean and dry, observe skin frequently while rendering care, reporting any red/opened areas promptly, weekly body audits. Resident has a right medial ankle unstageable -Turn and reposition resident every 2 hours and PRN. Monitor for s/s of infection. Notify MD immediately if s/s occur. Consult wound care specialist for further evaluation and treatment as appropriate. Resident has a left medial shin unstageable. Reposition resident every 2 hours and as needed. Monitor for s/s of infection. Notify MD if s/s occur. Review of S6WCN's treatment notes revealed, in part: 08/12/2021, during wound care treatment, S6WCN noticed resident had an unstageable pressure ulcer to his right lateral great toe. The skin was soft and boggy, surrounding skin macerated due to bandage soiling. Scant drainage. MD Notified 08/18/2021, resident has a right medial foot bunion aspect unstageable pressure ulcer with a small amount of liquefying necrotic tissue. Mild odor noted. Surrounding skin macerated. Bandages applied for wounds were soiled with urine. MD Notified 09/02/21, during wound care treatment, S6WCN noticed resident had a stage 2 pressure ulcer to his right foot [CONDITION(S)], area between great toe and first toe with scant drainage and surrounding skin a light pink color. Indention noted along front of great toe. 10/07/2021, during wound care treatment, S6WCN noticed resident had an unstageable pressure ulcer to his right bottom foot pad. Small amount of liquefying necrotic tissue. Surrounding skin macerated due to soiling of bandages from previous treatment. Dressing becomes soiled with urine and feces seeping around brief. MD Notified. RP Notified. S6WCN is concerned about Resident #1's condition and how he is receiving wound care. 10/26/2021, resident continues to have dressing soiled to wound sites with urine/feces due to contractures. Deterioration noted to right bottom footpad, strong pungent odor, macerated wound edges, moderate amount of liquefying necrotic tissues. Right foot [CONDITION(S)] between 1st and 2nd digit beginning to connect with right bottom footpad wound with scant drainage and macerated wound edges. Right medial foot bunion aspect skin thinning can feel bone, scant drainage, strong odor, macerated wound edges. Right great toe unstageable, scant drainage, macerated wound edges. Resident has a stage 3 pressure ulcer noted to the right lateral mid foot with moderate amount of drainage, surrounding skin macerated, and strong pungent odor. Unstageable pressure ulcer was noted to the right medial heel, moderate liquefying necrotic tissue drainage, and macerated wound edges. Stage 3 pressure ulcer to the right lateral malleolus superior and inferior with scant drainage and macerated wound edges. MD, S5ADON, and S4DON notified. 10/28/2021 Late Entry, 10/27/2021 Resident continued to have an increase in deterioration of wounds to right foot. Wound dressing soiling with urine noted. MD, S4DON, and S5ADON were made aware of deterioration. MD was notified of further deterioration on 10/27/2021. New order to have resident sent to ER for further evaluation and treatment. Review of Resident #1's Treatment Administration Record from 08/01/2021 - 11/14/2021 revealed the following, in part: Wound care was missed on the following dates Right Great toe -09/18/2021, 09/26/2021, 10/16/2021, 10/18/2021, Right Second toe - 09/18/2021, 10/16/2021, 10/18/2021 Right Medial Foot - 09/25/2021, 09/26/2021, 10/16/2021, 10/17/2021, 10/18/2021 Right Medial Ankle - 09/12/2021, 09/19/2021, 09/26/2021, 10/19/2021, 11/13/2021, 11/14/2021 Left Medial Shin - 9/26/2021, 10/19/2021 Right Medial Heel - 11/13/2021, 11/14/2021 Right Lateral Mid Foot - 11/13/2021, 11/14/2021 Right Bottom Footpad - 10/16/2021, 10/17/2021, 10/18/2021, 10/19/2021, 11/13/2021, 11/14/2021 Right Lateral Ankle - 11/13/2021, 11/14/2021 Review of Resident #1's hospital records from 10/27/2021 revealed, in part: Resident #1 has [CONDITION(S)] from a gangrenous right foot with [CONDITION(S)]. This has been brewing for a while. Patient will likely need an amputation. Assessment of the patients right foot and ankle completed this morning due to patient continues to refuse an amputation, despite being told the dangers of having bone infection in the foot, including spread of infection, loss of limb, and death. At the end of discussion, family decided to proceed with hospice care. Review of S6WCN's treatment note's from November 2021 and December 2021 revealed Resident #1 returned to the facility on [DATE] with hospice care. He had new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Nurses notes for November 2021 revealed the following, in part: 11/5/2021, resident returned from hospital. Hospital reported gangrene to the right toes, amputation refused. Hospice to evaluate patient per facility. Review of Resident #1's Hospice admit records for 11/05/2021 revealed, in part: admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 11/24/2021 at 9:10 a.m. with S6WCN. She confirmed being responsible for Resident #1's wound treatments. She stated he required wound dressing changes daily. She stated the nursing staff was not providing adequate incontinent care to Resident #1 and keeping him clean. She explained that when she changed the wound dressings, they were often saturated in urine and/or feces. She confirmed wound deterioration and infection started as a result of the bandages being frequently saturated with urine and/or feces. She stated on 08/12/2021, she told S5ADON, S4DON, and S10CNASup Resident #1 was not receiving adequate incontinent care. She said would document when she found the resident with soiled bandages and continued to let S5ADON, S4DON, and S10CNASup know. She stated the problem was not addressed and Resident #1 continued to have soiled bandages over his wound until he came back from the hospital with a Foley catheter 11/05/2021. She stated it was difficult to obtain orders for S13MD and she often required S4DON or A5ADON to help her get orders. She confirmed this caused problems with receiving orders promptly and delayed appropriate wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the facility was supposed to have someone come in on the weekends to perform wound care, but that did not always happen and wound care was not done on those days. An interview was conducted on 11/30/2021 at 10:55 a.m. with S4DON. She confirmed she was responsible for supervising S6WCN and assessing wounds weekly. She confirmed S6WCN nurse told her on multiple occasions that Resident #1 was soiled with urine and/or feces when they went in to do wound care. She stated she tried to make rounds, but she was not sure if the CNAs were actually changing Resident #1. She said herself, S5ADON, and S10CNASup could rounds during the day but the night shift did not have staff available to make rounds. She explained there was no way to make sure the night shift nursing staff was providing incontinent care to Resident #1. She stated S13MD was Resident #1's physician. She said S13MD had made her aware she was uncomfortable with providing wound care orders and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she suspected Resident #1 had Gangrene in his foot in September of 2021, but failed to notify the physician or send the resident out sooner than 10/27/2021. An interview was conducted on 11/30/2021 at 8:56 a.m. with S5ADON. She confirmed knowing the facility had problems with obtaining wound care orders for the residents followed by S13MD. She explained S6WCN would try to contact S13MD for orders, but S13MD would not answer. She stated S6WCN would then let herself or S4DON know she was having problems obtaining orders and we would try to get them. She stated S13MD would answer them sometimes and other times it would be 3 to 4 days before they could get a response for an order. She stated, sometimes S27NP would sign the orders that S13MD did not. She stated on 11/19/2021, S13MD came into the facility and refused to sign orders for wound care, labs, etc. S13MD said she did not feel comfortable signing any orders because she did not specialize in wound care. She stated she told S1Owner the facility was having issues with S13MD providing orders for wound treatment on 11/19/2021. An interview was conducted on 11/30/2021 at 11:07 a.m. with S10CNASup. She stated CNAs were supposed to make rounds on the residents every 2 hours. She explained they are to check the incontinent residents to see if they are soiled and should change them immediately in they are. She confirmed knowing Resident #1 was not being cleaned and changed every 2 hours or when he was soiled. She said she had not conducted an in-service with the CNAs regarding providing incontinent care. She stated in the evenings there was not a supervisor so the facility relied on the honor system to ensure residents were being taken care of. She stated Resident #1 being left soiled was not an issue because S6WCN would change him when she changed the dressings. She confirmed S6WNC did not change the wound dressings care every 2 hours for Resident #1. An interview was conducted on 12/01/2021 at 12:30 p.m. with S9WCA. He stated Resident #1's right foot appeared to be improving in August 2021, but the CNAs stopped changing him every 2 hours. He stated Resident #1's legs were contracted and the urine/feces would get on the bandages. He said when he would go into the room to assist S6WCN, Resident #1 would be covered in feces and/or urine. He stated S6WCN and himself told S10CNASup, S4DON and S5ADON Resident #1 was not being cleaned or changed adequately. He stated nothing was implemented to make sure the CNAs were providing incontinent care and Resident #1 continued to have soiled dressings on his wounds for long periods. He stated he could see Resident #1's wounds getting worse and worse. He stated Resident #1 should have been sent to the hospital way before 10/27/2021 due to the severity of his wounds. He stated was present numerous times when S6WCN would call S13MD for wound care orders and receive no answer. S6WCN would then go to S5ADON or S4DON so they could get in touch with S13MD. He stated S4DON and S13MD were aware of how bad Resident #1's wounds were and that they were deteriorating. An interview was conducted on 12/01/2021 at 2:22 p.m. with S13MD. She said she made the facility aware in September 2021 through zoom meetings, in person meetings, and text messages she was not comfortable writing orders for wound care as that was not her specialty. She stated she never physically saw Resident #1's foot wounds in person and never signed wound care orders. She stated she received a text message on 10/27/2021 from S6WCN with a picture of Resident #1's right foot wound. She stated she told the facility there was no way the resident's foot got like that overnight, and that she was never notified of the severity until that day. She stated she gave orders to send him to the hospital and suspected [CONDITION(S)] and gangrene from the picture. Resident #3 Review of the clinical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses, which included: End Stage [CONDITION(S)] on [CONDITION(S)], [CONDITION(S)] of the Left Foot status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS with an ARD of 10/08/2021 revealed Resident #3 had a BIMS of 14, which indicated he was cognitively intact. Review of Resident #3's current Care Plan revealed the following, in part: I have a left foot amputation. I require nursing staff to monitor for red areas or breaks in skin. Review of Resident #3's wound care orders revealed the following, in part: 10/01/2021 to 10/31/2021 Left foot amputation site: cleanse with wound cleaner, Pat dry, apply dry gauze, kerlix and secure with ace bandage daily. Review of Resident #3's treatment administration record (TAR) for October 2021 revealed on 10/16/2021, 10/17/2021, 10/18/2021, and 10/19/2021 Resident #3 did not receive wound care as indicated by no initials on the TAR. Review of Resident #3's wound care notes revealed in part, the following: 10/01/2021, Left toes 1-5 digit amputation noted. 11x0.1x0.1, 8 sutures still noted intact. Scant drainage. No pungent odor, no c/o pain or discomfort. Swelling noted. 10/22/2021- Amputation site is open, increase in drainage, pink in color, sutures are intact, embedding. Sent to emergency room for evaluation and suture removal. 10/23/2021- Further evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was sent to the hospital on 10/22/2021 and returned the same day. Assessment of site: Sutures were removed. Small amount of purulent drainage noted. Swelling present. Review of Resident #3's hospital record from 10/22/2021 revealed in part: Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #3 nurse's notes revealed the following in part: 11/01/2021, Nurse called to dining room. Resident stated he was dizzy, upon arrival resident started to loose consciousness. Ambulance called, in route to emergency room . Review of Resident #3's hospital records from 11/01/2021 to 11/11/2021 revealed in part: History and Physical: 11/10/2021 Resident #3's incision dehisced and there is now a deep wound present. Several non-absorbable sutures are also still in the foot. The sutures are not holding together the incision, but rather imbedded within the skin on either side of the incision. Ulcer of left foot with Necrotic tissue, biofilm, slough, necrotic subcutaneous tissue, and necrotic fascia was debrided from the wound base. Post wound measurements were approximately 8 cm in length by 3 cm in width by 1 .5 cm in depth. Wound extends to fascia. Wound VAC ordered with twice-weekly dressing changes. Wound Care Notes: 11/11/2021 Patient is okay to be discharged with outpatient follow-up, wound clinic and wound VAC with dressing changes twice weekly. Wound VAC ordered with twice-weekly dressing changes. Negative Pressure Wound Treatment is medically necessary for this patient at this time to achieve acceleration of granulation tissue and wound closure. It is my clinical judgement that this cannot be achieved using topical dressing or medications. Plan of Care: 11/11/2021 Discharge orders faxed and S16BOM confirmed receipt. Resident #3 cleared for return to the facility. S16BOM confirmed they have a wound vac ready for Resident #3. Review of Resident #3's facility's clinical record revealed he was readmitted to the facility on [DATE] with additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Wound care notes revealed the following, in part: 11/12/2021, Resident #3 was returned to facility. Readmit wound assessment. Treatment continues with resident's left foot amputation site, deterioration noted to site. 10.8x2.5x1.5 granulation noted with islands of epithelial tissue noted in between, 25% slough noted to wound bed. Moderate amount of drainage. Surrounding skin pink in color. Mild pungent odor noted. Resident denies pain and discomfort to site. Resident was treated with a wound vac while in hospital. Wound vac orders discontinued upon discharge. New wet to dry order to cleanse with wound cleaner pat dry, apply NS soaked gauze, cover with ABD pad and secure with kerlix. Treatment administered resident tolerated well. - Review of Resident #3's facility's wound care orders revealed the following in part: 11/12/2021 Left foot amputation site, cleanse with wound cleaner, pat dry and apply normal saline soaked gauze, cover with ABD pad, secure with kerlix every day. Review of Resident #3's facility's treatment administration record (TAR) for November 2021 revealed on 11/13/2021 and 11/14/2021 Resident #3 did not receive wound care, which was indicated by no initials on the TAR. Review of Resident #3 facility's nurse's notes revealed the following, in part: 11/ 1, During report Resident #3 requested to go to the hospital. Ambulance notified and in route to local emergency room . Review of Resident #3's hospital record from 11/15/2021 revealed in part: 11/15/2021 History and Physical Resident #3 presented to the hospital on 11/15/2021 with a primary complaint of left Foot Pain. Patient tells me that since he was discharged 4 days ago, a wound VAC was not placed at the facility as ordered. Resident #3's wound dressing was not changed as his wound dressing still has the date he was discharged from the hospital. Patient looks unkempt and has purulent drainage from the site of the wound; he also has foul-smelling discharge and [CONDITION(S)] around his groin area and underneath his abdominal folds. An interview was conducted on 11/22/2021 at 11:42 a.m. with S6WCN. She said Resident #3 was admitted to the facility on [DATE]. She said upon admission she noted Resident #3 had sutures in place to his surgical wound. She explained post op surgical residents should have sutures removed after 7-14 days. She denied contacting the physician to clarify when Resident #3's sutures should be removed. She said on 10/22/2021, Resident #3's foot was swollen and the sutures were embedded into the skin. She said she contacted S13MD on the same day and received an order to send Resident #3 to the emergency room for suture removal. She confirmed it was her responsibility to inform S19MR when a resident needed a suture removal appointment and she had not done that. She also confirmed Resident #3 should have had the sutures removed before 10/22/2021. She said Resident #3 was sent out of the facility on 11/01/2021 and returned ton 11/11/2021. She stated she received the email from S16BOM with the hospitals wound care orders and had ordered a wound vac for Resident #3 prior to him returning to the facility on [DATE]. She stated on 11/12/2021, she reviewed the discharge paperwork from the hospital and did not see any wound care orders. S6WCN stated received report from the nurse discharging Resident #3. She said the discharging nurse told her the wound vac was discontinued and wound care was wet to dry dressing change every day. She stated the discharging nurse did not mention orders for a wound vac during the report. She confirmed she did not clarify Resident #3's wound care orders with a physician and transcribed the wound care instructions from the discharging hospital nurse to an order sheet. She said she completed a wet to dry dressing change on 11/12/2021 and did not apply the wound vac. She stated she did not work on 11/13/2021 and 11/14/2021, and did not complete Resident #3's wound care on those days. An interview was conducted on 11/22/2021 at 9:11 a.m. with S20LPN. She confirmed she worked on 11/13/2021 and was assigned to Resident #3. She confirmed on 11/13/2021 she did not complete wound care. An interview was conducted with the hospital Physician on 11/22/2021 at 10:11 a.m. She confirmed the local hospital and the facility coordinated care for Resident #3 to have a wound vac placed on his left foot when he returned to the facility. She confirmed when Resident #3 was readmitted to the hospital on 11/15/2021, he did not have a wound vac in place and his dressing was still dated 11/11/2021. An interview was conducted on 11/23/2021 at 12:00 p.m. with S18BOM. She said on 11/10/2021, she received an email from the hospital informing the facility Resident #3 would need a wound vac. She said she forwarded the email to nursing administration, S1Owner and S2Owner. She said on 11/11/2021, she informed the Case Manager at the hospital that the facility had the wound vac and was ready for Resident #3. She confirmed she received an email on 11/11/2021 at 9:14 a.m. that confirmed the hospital would remove the wound vac prior to discharge and confirmed the facility would apply their own wound vac upon readmission. She confirmed she did not forward this email to nursing or administration and should have. An interview was conducted on 11/23/2021 at 4:12 p.m. with S4DON. She was aware Resident #3 was admitted to the facility on [DATE] and had 8 sutures. She said she was also aware the sutures were not removed and the resident had to be sent to the emergency roiagnom on [DATE] for removal. She said she had received the email from S18BOM that stated Resident #3 was to be discharged with a wound vac. She explained when Resident #3 returned to the facility on [DATE] he did not have any wound care orders. She said the floor nurse would be responsible for contacting the physician for verbal orders if a resident returned to the facility without them and S6WCN would verify the wound orders. She stated she did not know S6WCN obtained the orders from the discharging nurse and failed to verify them with a physician. She confirmed S6WC should have verified the orders with the physician prior to implementation. S4DON reviewed Resident #3's treatment records. She confirmed the wound care was not completed on the following dates; 10/16/2021, 10/17/2021, 10/18/2021, 10/19/2021, 11/13/2021 and 11/14/2021 by the nurse as it should have been. She stated if the wound care nurse was not in the facility that the nurses should have completed wound care. An interview was conducted on 11/30/2021 at 8:47 a.m. with S19MR. She confirmed she was responsible for scheduling follow up appointments. She state

Based on observations, interviews and record reviews, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and maintain the highest practical and mental needs for 3 (#1, #3, R1) out of a total of 11 (#1, #2, #3, #4, #5, R1, R2, R3, R4, R5, R6) sampled residents. The facility failed to ensure nursing staff demonstrate competency in skills and techniques to care for residents with wounds. The deficient practice resulted in an immediate jeopardy situation on 10/27/2021 when Resident #1 continued to have increase in deterioration of wounds to right foot. Resident #1 was incontinent with right and left knee contractures. Resident had been observed by staff multiple times with his wound dressing saturated with urine and feces. The physician was contacted on 10/27/2021, and the resident was sent to the hospital. Resident #1 returned to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice resulted in an immediate jeopardy situation for Resident #3 on 11/15/2021 when the resident experienced increased pain to the left foot and purulent drainage from the site of the wound. Resident #3's 11/11/2021 hospital discharge order for a wound vac was not initiated and the wound dressing had not been changed by the facility's staff. The resident was readmitted to the hospital on 11/15/2021. The resident was diagnosed with Ulcer of Left Foot with Necrosis of Muscle. S2Owner and S3ADM were notified of the Immediate Jeopardy on 12/01/2021 at 8:06 p.m. The Immediate Jeopardy was removed on 12/03/2021 at 6:30 p.m. when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following had been initiated and/or implemented prior to exit. The Immediate Jeopardy Plan of removal included: 1. The facility failed to ensure nursing staff had appropriate competencies and skills sets to provide nursing and related services to residents with wounds, WoundVacs, incontinent care, and to assess the resident's level of consciousness prior to administering a liquid medication orally. a. Effective 12/03/2021, a Nursing Assistant Clinical Skills Checklist and Competency Evaluation has been implemented to review vital information, policies, and competencies for all CNAs. This CNA Skills Checklist will be completed upon hire during orientation, and annually thereafter or as needed. All CNAs will complete the Nursing Assistant Clinical Skills Checklist and Competency Evaluation by 12/31/2021. b. Effective 12/03/2021, a Nurse Skills Review Packet has been implemented to review vital information, policies, and competencies for all facility nurses, which includes a Nurse Competency Medication Pass Observation. PCSA, the facility's pharmacy consultant group, provided a Medication Administration Checklist, Med-Pass Guidelines, and Medications with Shortened Expiration Dates to be added to the Nurse Skills Review Packet. This Nurse Skills review Packet will be completed upon hire during orientation, and annually thereafter or as needed by the DON or nurse designee. All facility nurses will complete the Nurse Skills Review Packet by 12/31/2021. c. The facility's DON and ADON will be in-serviced on 12/03/2021 by facility-hired consultants regarding CNAs' and Nurses' Skills Checklist and Competency Evaluation importance of compliance before providing direct car for residents. The facility's DON and ADON will be responsible for ensuring skills compliance annually and as needed thereafter. Once the facility's DON or ADON sign-off on skills competencies, the checklist will be given to Human Resources to be placed in the employee's permanent file. d. On-going monitoring will be conducted at random, unannounced times to ensure that compliance is being achieved. The immediate Jeopardy was removed on 12/03/2021 at 6:30PM for Resident #1 and Resident #3, and remains as an actual harm for resident #1 and #3. The deficient practice remains as a likelihood for more than minimal harm for the remaining residents identified with wounds in the facility. Findings: Resident #1 Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnosis, which included: [CONDITION(S)] Following Cerebral Infarction Right Side Dominant, Blister Left Thigh, Laceration Without Foreign Body of Right Elbow, Unspecified Open Wound Left Lower Leg, and Contracture Right and Left Knee. Review of the MDS with an ARD of 09/29/2021 revealed Resident #1 had a BIMS of 3, which indicated he was severely cognitively impaired. Functional Status was total dependent in bed mobility, transferring, dressing, eating, toileting. Resident was always incontinent, Resident has 3 Stage III Pressure Ulcers, 3 Unstageable Pressure Ulcers. Review of Resident #1's current Care Plan revealed the following, in part: Resident requires assistance with ADLs secondary to [CONDITION(S)] with right sided weakness, [CONDITION(S)]. Assist resident with clean clothes daily and prn soilage. Every two hour rounds assisting with turning, assessing for needs. Resident at risk for pressure ulcers secondary to incontinence episodes, decreased mobility. Keep skin clean and dry, observe skin frequently while rendering care, reporting any red/opened areas promptly, weekly body audits. Resident has a right medial ankle unstageable. Turn and reposition resident every two hours and PRN. Monitor for signs and symptoms of infection. Notify MD immediately if signs and symptoms occur. Consult wound care specialist for further evaluation and treatment as appropriate. Lift resident when repositioning in bed, ensure heel protectors are worn as tolerated. Resident has a left medial shin unstageable. Ensure pillow wedge is between both legs for alleviation of pressure and prevention of skin break down. Reposition resident every two hours and as needed. Monitor for signs and symptoms of infection. Notify MD if signs and symptoms occur. Review of Resident #1's Physician Orders for wound care revealed, in part: 05/28/2021 Right Medial Ankle Unstageable Cleanse with wound cleaner, pat dry, apply Collagen particles and Xeroform 5x9 guaze strip, cover with Kerlix dressing every other day and as needed for soiling. 05/28/2021 Left Medial Shin Unstageable Cleanse with wound cleaner, pat dry, apply Santyl ointment and Xeroform, and cover with a clean dry dressing every other day. 08/12/2021 Right Great Toe Unstagable Cleanse with wound cleaner, pat dry, apply Santyl ointment, Collagen particles, and Xeroform. Wrap with Kerlix dressing every other day. 08/18/2021 Right Medial Foot Unstageable Cleanse with wound cleaner, pat dry, apply Santyl ointment, Collagen, and Xeroform. Secure with Kerlix dressing daily. 09/02/2021 Right Foot [CONDITION(S)] (Between great toe and 2nd toe) Stage II Cleanse with wound cleaner, pat dry, apply Collagen and Xeroform 5x9 gauze strip, cover with a clean dry dressing, secure with Kerlix every other day. 10/07/2021 Right Bottom Footpad Unstageable Cleanse with wound cleaner, pat dry, apply Santyl, Collagen and Xeroform. Secure with Kerlix dressing daily. 10/26/2021 Right Lateral Mid Foot Stage III Cleanse with wound cleaner, pat dry, apply Santyl Ointment and Dankins 0.5% soaked gauze, cover ABD pad, wrap with Kerlix, secure with tape daily. 10/26/2021 Right Bottom Footpad Unstageable Cleanse with wound cleaner, pat dry, apply Santyl ointment and Dankins 0.5% soaked gauze, cover with ABD pad, wrap with Kerlix, secure with tape daily. 10/26/2021 Right Great toe Unstageable Cleanse with wound cleaner, pat dry, apply Santyl Ointment, Dankins 0.5% soaked gauze, cover with ABD pad, wrap with Kerlix secure with tape daily. 10/26/2021 Right Medial Foot Unstageable Cleanse with wound cleaner, pat dry, apply Santyl Ointment, Dankins 0.5% soaked gauze, cover with ABD pad, wrap with Kerlix secure with tape daily. 11/05/2021 Right Lateral Ankle Stage III (Superior and Inferior) Cleanse with Dankins, pat dry, apply gauze and ABD pad, wrap with Kerlix, secure with ace wrap daily and PRN for soiling. 11/05/2021 Right Bottom Footpad Unstageable Cleanse with Dankins, pat dry, apply gauze and ABD pad, wrap with Kerlix, secure with ace wrap daily and PRN for soiling. 11/05/2021 Right Medial Ankle Unstageable Cleanse with Dankins, pat dry, apply gauze and ABD pad, wrap with Kerlix, secure with ace wrap daily and PRN for soiling. 11/05/2021 Right Medial Heel Unstageable Cleanse with Dankins, pat dry, apply gauze and ABD pad, wrap with Kerlix, secure with ace wrap daily and PRN for soiling. 11/05/2021 Right Lateral Mid Foot Stage III Cleanse with Dankins, pat dry, apply gauze and ABD pad, wrap with Kerlix, secure with ace wrap daily and PRN for soiling. Review of Resident #1's Treatment Administration Record from 08/01/2021 - 11/14/2021 revealed wound care was missed on the following dates: Right Great toe -09/18/2021, 09/26/2021, 10/16/2021, 10/18/2021, Right Second toe - 09/18/2021, 10/16/2021, 10/18/2021 Right Medial Foot - 09/25/2021, 09/26/2021, 10/16/2021, 10/17/2021, 10/18/2021 Right Medial Ankle - 09/12/2021, 09/19/2021, 09/26/2021, 10/19/2021, 11/13/2021, 11/14/2021 Left Medial Shin - 9/26/2021, 10/19/2021 Right Medial Heel - 11/13/2021, 11/14/2021 Right Lateral Mid Foot - 11/13/2021, 11/14/2021 Right Bottom Footpad - 10/16/2021, 10/17/2021, 10/18/2021, 10/19/2021, 11/13/2021, 11/14/2021 Right Lateral Ankle - 11/13/2021, 11/14/2021 Review of Treatment Nurse's Notes from 08/12/2021 to 11/2021 for Resident #1 revealed, in part: 08/12/2021- During wound care treatment noticed resident had an unstageable to his right lateral great toe. Skin is soft and boggy, surrounding skin macerated due to bandage soiling. Scant drainage. MD Notified 08/18/2021- Resident has a right medial foot bunion aspect unstageable small amount of liquefying necrotic tissue. Mild odor noted. Surrounding skin macerated. Resident is extremely contracted to both lower extremities. Bandages applied for wounds soiled with urine. MD Notified 09/02/2021- During wound care treatment noticed resident had a stage two to his right foot [CONDITION(S)], area between great toe and first toe scant drainage surrounding skin light pink color. Indention note along front of great toe. RP called. 10/07/2021- During wound care treatment noticed resident had an unstageable to his right bottom footpad. Small amount of liquefying necrotic tissue. Surrounding skin macerated due to soiling of bandages for previous treatment. Resident has right and left lower extremity contracture noted where both feet are bent upward touching brief. Dressing becomes soiled with urine and feces seeping around brief. MD Notified. RP Notified. Concerned about resident condition and how he is receiving wounds. 10/26/2021 - Resident continues to have dressing soiling to wound sites with urine/feces due to contractures. Deterioration noted to right bottom footpad, strong pungent odor, macerated wound edges, moderate amount of liquefying necrotic tissues. Right foot [CONDITION(S)] between first and second digit beginning to connect with right bottom footpads wound scant drainage, macerated wound edges. Right medial foot bunion aspect skin thinning can feel bone, scant drainage, strong odor, macerated wound edges. Right great toe unstageable, scant drainage, macerated wound edges. Resident has stage three noted right lateral mid foot moderate amount of drainage, surrounding skin macerated, strong pungent odor. Unstageable noted right medial heel, moderate liquefying necrotic tissue drainage, macerated wound edges. Stage three right lateral malleolus superior and inferior scant drainage, macerated wound edges. MD, S5ADON, and S4DON notified. 10/28/2021 Late Entry 10/27/2021 Resident continued to have increase in deterioration of wounds to right foot. Wound dressing soiling with urine noted. MD, S4DON, and S5ADON were made aware of deterioration. MD was notified of further deterioration 10/27/2021. New order to have resident sent to emergency room for further evaluation and treatment. 11/05/2021 Resident was readmitted to facility 11/05/2021. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident returned to facility on hospice. Purulent drainage noted. Loud pungent smell noted to right foot. 11/29/2021 Hospice nurse notified of residents overall decline. Review of Nurse's Notes from 11/29/2021 for Resident #1 revealed, in part: Addendum made 11/29/2021 - Clarification for sequence of events to 8:45 a.m. note. Resident assessed at this time Vitals blood pressure 97/64, respirations 30, Pulse 140, Temperature 99.1. Resident responds to tactile stimuli only when moved hand to check turgor and manual vitals. Resident usually alert, awake, and oriented to person and engages in conversation. [MEDICATION(S)] 0.5ml and Lorazepam 0.25ml administered as ordered on Medication Administration Record. Awaited to hear resident swallow. Resident noted making gurgling noises as if was about to vomit. Head of bed then elevated. No emesis observed. Called respiratory to bring suction. Suction placed at bedside. 11/29/2021 12:30 p.m. New orders from Hospice nurse for chest x-ray to rule out aspiration. An interview was conducted on 11/24/2021 9:10 a.m. with S6WCN. She stated she was familiar with Resident #1 and that his wounds were present prior to her beginning in April 2021. She stated she noticed a decline in August 2021. She stated starting in August 2021, incontinent care was not taking place, his wounds started getting worse, and he was sent to the hospital. She stated when his right foot got worse, she contacted S13MD, and that is whom she obtained her wound care orders from. She stated she told S5ADON, S4DON, and S10CNASup from August to October that Resident #1 was not receiving adequate incontinent care. She stated when she would change his dressings, he would be covered in urine and/or feces, his dressings would be saturated, and she noticed deterioration in the wounds. She stated she feels the deterioration started due to the resident's bandages being saturated with urine. When asked about missed wound care according to treatment administration record (TAR), she stated the facility was supposed to have a wound care nurse come in on the weekends that S6WCN was not available but that does not always happen so wound care got missed. An observation was made on 11/29/2021 at 8:40 a.m. of Resident #1. Resident #1 had no response when asked questions. His eyes were slightly open, not blinking, lying still with the head of the bed below 30 degrees, and his mouth open. S11LPN came into the room at 8:47 a.m. to check vitals: Temperature 99.1 temporal, Blood Pressure 97/64, Pulse 144, Respirations 30. Resident #1 grimaced when she moved his arm to check his blood pressure. At 8:53 a.m., S11LPN gave the resident liquid [MEDICATION(S)] and [MEDICATION(S)] through a syringe into the resident's mouth which continued to stay open. When asked why she gave the resident [MEDICATION(S)] and [MEDICATION(S)], she stated to lower his respirations and pulse. When asked if he swallowed the medication, S11LPN responded, I think he swallowed it. The resident was lying in bed, mouth open, still unresponsive. S11LPN asked the resident if he swallowed, but a response was not made. At 8:58 a.m., Resident #1 started gurgling, surveyor told S11LPN to sit Resident #1 up multiple times. The nurse looked around the room for a remote to raise the head of the bed, then sat the head of the bed up. Resident #1 stopped gurgling, and appeared to have swallowed the medication. S11LPN walked out of the room, and back in at 9:06 p.m. stating she called hospice. An interview was conducted on 11/29/2021 at 11:37 a.m. with S4DON. She stated that if there is a change in condition or decline of a resident, she should be notified. She stated if a resident is unresponsive, a medication should not be given by mouth do to choking hazards. She stated she had not been informed of S11LPN giving any medications to Resident #1 while unresponsive, and was not informed of any change in Resident #1. She stated Resident #1's bed should have been at 30 degrees or higher due to him having a PEG tube, and especially before giving any medication orally. An interview was conducted on 11/30/2021 at 8:56 a.m. with S5ADON. She stated she and S4DON met with S11LPN at the end of her shift on 11/30/2021. S5ADON stated they asked S11LPN to write a new statement with exactly what happened. S5ADON stated S11LPN was looking for the remote to the bed. S11LPN replied I was, the remote was on the floor, S5ADON stated S11LPN should have physically sat Resident #1 up by using her arms instead of the remote to the bed, and that the head of the bed should have been 30 degrees or higher to begin with. S5ADON told S11LPN she wrote she gave [MEDICATION(S)] for pain and lorazepam for anxiety, and if the resident was unresponsive then he could not be in pain or have anxiety. An interview was conducted on 11/30/2021 at 10:55 a.m. with S4DON. She stated S6WCN nurse informed her on multiple occasions Resident #1 had soiled briefs and dressings when they went in to do wound care. She stated she spoke with S10CNASup about making more rounds. She stated she felt his wounds deteriorated due to the bandages being soiled and staying soiled until wound care arrived. She stated she was obtaining orders from S13MD on treatments for his right foot, but confirmed she should have requested he be sent to the hospital sooner. She stated she made rounds, but she is unsure if the CNAs were actually changing Resident #1. She stated she, S5ADON, and S10CNASup made rounds during the day but the night shift did not have anyone to make rounds on them. She stated there was no way to make sure the night shift was doing what they are supposed to do except for accountability because there was no supervision at night. An interview was conducted on 11/30/2021 at 11:07 a.m. with S10CNASup. She stated she was aware that Resident #1 was not being changed every two hours or when he was soiled. She stated she did not think Resident #1 not being changed was an issue because wound care was changing him when they would go in there. When asked if that was the only time he was being changed, she stated she would change him sometimes too. She stated in the evenings there was not a supervisor so they rely on the honor system for residents to be taken care of. An interview was conducted on 12/01/2021 at 12:30 p.m. with S9WCA. He stated the CNAs were no longer changing Resident #1 and every time he and S6WCN would go into the room, Resident #1 was covered in feces and/or urine. He verified Resident #1's wounds were deteriorating. He stated S6WCN nurse and himself told S10CNASup, S4DON and S5ADON about Resident #1 not being clean or changed. He stated nothing was done to address the lack of incontinent care provided to Resident #1. Resident #3: Review of the clinical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses, which included: End Stage [CONDITION(S)] on [CONDITION(S)], [CONDITION(S)] of the Left Foot status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS with an ARD of 10/08/2021 revealed Resident #3 had a BIMS of 14, which indicated he was cognitively intact. Review of Resident #3's current Care Plan revealed the following, in part: I have a left foot amputation. I require nursing staff to monitor for red areas or breaks in skin. Cleanse with wound cleaner, pat dry, apply dry gauze, Kerlix and secure with ace bandage daily. Review of Resident #3's wound care orders revealed the following in part: 10/01/2021 to 10/31/2021 Left foot amputation site: cleanse with wound cleaner, Pat dry, apply dry gauze, Kerlix and secure with ace bandage daily. Noted to be written on Physician Telephone Order sheet with MD name and date. Review of Resident #3's treatment administration record (TAR) for October 2021 revealed on 10/16/2021, 10/17/2021, 10/18/2021, and 10/19/2021 were not initialed, which indicated wound care was not done. Review of Resident #3's wound care notes revealed in part the following: 10/01/2021- Left toes 1-5 digit amputation noted. 11x0.1x0.1, 8 sutures still noted intact. Scant drainage. No pungent odor, no c/o pain or discomfort. Swelling noted. 10/22/2021- Amputation site is open, increase in drainage, pink in color, sutures are intact, embedding. Sent to emergency room for evaluation and suture removal. 10/23/2021- Further evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was sent to a local hospital on 10/22/2021. Resident returned to facility 10/22/2021. Assessment of site, sutures were removed. Small amount of purulent drainage noted. Swelling present. Review of Resident #3's hospital records from 10/22/2021 revealed in part: emergency room MD documented; I did speak with his managing plastic surgery service who recommended removal of visible sutures and outpatient follow up. I do not think antibiotics or emergent surgical intervention this evening is indicated. He is appropriate for close outpatient clinical follow-up. Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #3 nurse's notes revealed the following in part: 11/01/2021 at 12:30 P.M. Nurse called to dining room. Resident stated he was dizzy, upon arrival resident started to lose consciousness. Ambulance called, in route to local emergency room . Review of Resident #3's hospital records from 11/01/2021 to 11/11/2021 revealed in part: History and Physical dated 10/10/2021. Resident #3's incision has dehisced and there is now a deep wound present. Several non-absorbable sutures are also still in the foot. The sutures are not holding together the incision, but rather imbedded within the skin on either side of the incision. Ulcer of left foot with Necrotic tissue, biofilm, slough, necrotic subcutaneous tissue, and necrotic fascia was debrided from the wound base. Post wound measurements were approximately 8 cm in length by 3 cm in width by 1.5 cm in depth. Wound extends to fascia. Wound VAC ordered with twice-weekly dressing changes. Wound Care Notes dated 11/11/2021. Patient is okay to be discharged from a podiatry standpoint with outpatient follow-up, wound clinic, and wound VAC with dressing changes twice weekly. Wound VAC ordered with twice-weekly dressing changes. Negative Pressure Wound Treatment is medically necessary for this patient at this time to achieve acceleration of granulation tissue and wound closure. It is my clinical judgement this cannot be achieved using topical dressing or medications. Plan of Care dated 11/11/2021. Discharge orders faxed via Epic and S18BOM confirmed receipt and cleared Resident #3 for return to the facility. S18BOM confirmed they have a wound vac ready for Resident #3. Review of the Business office emails regarding Resident #3's discharge from the hospital revealed the following: An email was received by S16BOM on 11/10/2021 at 2:16 p.m. Resident #3 is having a wound vac placed today and will be ready for discharge back to your facility tomorrow. Just reaching out to make sure you guys will be able to accept him back tomorrow and make accommodations for the wound vac. Please let me know. The above email was forwarded by S16BOM on 11/10/2021 at 2:48 p.m. to S1owner, S2owner, S4DON, S5ADON, S13MD, and S14WCS. An email was received by S16BOM on 11/11/2021 at 9:14 a.m. I understand everything is set for Resident #3 to come back to you? He has a wound vac. I understand this will be getting removed and you guys will place your own? Review of Resident #3's clinical record revealed he was readmitted to the facility on [DATE] with additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #3's Wound care notes revealed the following, in part: 11/12/2021- Resident returned to facility. Readmit wound assessment. Treatment continues with resident's left foot amputation site, deterioration noted to site. 10.8x2.5x1.5 granulation noted with islands of epithelial tissue noted in between, 25% slough noted to wound bed. Moderate amount of drainage. Surrounding skin pink in color. Mild pungent odor noted. Resident denies pain and discomfort to site. Resident was treated with a wound vac while in hospital. Wound vac orders d/c'd upon discharge. New wet to dry order to cleanse with wound cleaner pat dry apply NS soaked gauze cover with ABD pad secure with Kerlix. Treatment administered resident tolerated well. Review of Resident #3's wound care orders revealed the following in part: 11/12/2021 Left foot amputation site, cleanse with wound cleaner, pat dry and apply normal saline soaked gauze, cover with ABD pad, secure with Kerlix every day. Order was handwritten on an order sheet. There was no MD name, date and time of order received. Review of Resident #3's treatment administration record (TAR) for November 2021 revealed on 11/13/2021 and 11/14/2021 the TAR was not initialed, which indicated wound care was not done. Review of Resident #3 nurse's notes revealed the following in part: 11/15/2021 at 7:00 a.m. During report, Resident #3 requested to go to the hospital. Ambulance notified and in route to local emergency room . Review of Resident #3's hospital records from 11/15/2021 revealed in part: History and Physical dated 11/15/2021: Resident #3 presented to local hospital on 11/15/2021 with a primary complaint of Abdominal Pain (2AM) and Foot Pain (Left). Patient tells me since he was discharged 4 days ago, a wound VAC was not placed at the nursing home as ordered, no wound dressing was changed as his wound dressing still has the date he was discharged from the hospital. Patient looks unkempt and has purulent drainage from the site of wound, which was not changed at the nursing home; he also has foul-smelling discharge and [CONDITION(S)] around his groin area and underneath his abdominal folds. An interview was conducted on 11/22/2021 at 11:42 a.m. with S6WCN. She said Resident #3 was admitted on [DATE]. She said for post op surgical residents, sutures would be removed after 7-14 days. She said S19MR would make the follow-up appointments. She said if there were no orders at admit she would be responsible for getting orders from the attending physician for suture removal and informing S19MR to schedule an appointment. On 10/22/2021, she stated she noticed Resident #3 had sutures embedded in the skin with swelling to his left foot. She stated she contacted S13MD and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said Resident #3 returned the same day on 10/22/2021. She said she thinks the sutures could have come out sooner. On 11/01/2021, Resident #3 was sent to the ER due to [CONDITION(S)] episodes. Resident #3 returned to the facility on [DATE]. She confirmed she received the email with wound vac request for discharge for Resident #3 but it was never placed on the wound. On 11/11/2021, she received a verbal report from the discharging nurse at the local hospital the wound vac was discontinued and wound care would be wet to dry dressing changes daily. On Friday, 11/12/2021, she reviewed discharge papers from the local hospital and did not find any wound vac or wound care orders. She confirmed she did not call S13MD or the local hospital for order clarification and transcribed the wet to dry instructions she received in report as an order. She confirmed she completed a wet to dry dressing change on 11/12/2021. She confirmed she did not complete wound care on 11/13/2021 and 11/14/2021. She stated the nurse assigned to Resident #3 would complete wound care when she was not there. She was not aware if the weekend nurses knew she was not working that weekend. An interview was conducted on 11/22/2021 at 9:11 a.m. with S20LPN. She confirmed she worked on 11/13/2021 and was assigned to Resident #3. She confirmed on 11/13/2021 she did not do wound care. She said the wound care nurse comes in on the weekend and takes care of the residents. An interview was completed with S22HMD on 11/22/2021 at 10:11 a.m. She confirmed the local hospital and the facility-coordinated care for Resident #3 to have a wound vac placed on his Left foot. She confirmed when Resident #3 presented to the emergency roiagnom on [DATE], he did not have a wound vac in place and his dressing was dated 11/11/2021. An interview was conducted on 11/23/2021 at 12:00 p.m. with S18BOM. She said on 10/14/2021, S13MD requested an NP for wound care. She said the NP request was brought to the attention of S21FADM. She said she was unsure if S1Owner and S2Owner were aware of the request and was unsure what happened after S21FADM resigned. She said on 11/10/2021, she received an email from the local hospital informing the facility, Resident #3 would need a wound vac. She said she forwarded the email to S4DON, S5ADON, S6WCN, S14WCS, S13MD, S1Owner, and S2Owner. She said on 11/11/2021, she informed the Case Manager at the hospital that the facility had the wound vac and was ready for Resident #3. She said she received an email on 11/11/2021 at 9:14 a.m. which confirmed the hospital would remove the wound vac prior to discharge and confirmed the facility would apply their own wound vac at admit. She confirmed she did not forward this email to nursing or administration. An interview was conducted on 11/23/2021 at 12:30 p.m. with S13MD. On 10/22/2021, she stated S6WCN reported Resident #3 had sutures embedded in the skin with swelling to his left foot. She stated she provided an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she was not made aware of the resident being sent out to the hospital on 11/01/2021 or returning to the facility on [DATE]. She said she should have been notified. She said she was unaware of the hospital requesting a wound vac. She said she would have never agreed to that. She said in her opinion she did not feel the facility had enough staff for residents to be on a wound vac. She said over the past few months she has met with management/administration multiple times regarding her concerns of wounds. She said she was not a wound care physician and does not give wound care orders. She said on 10/14/2021, she provided a contact to S21FADM for a NP wound care specialist. On 11/02/21, she said she had a meeting with S4DON, S1Owner, S2Owner, and S5ADON. She said S14WCS was asking her to sign off some orders. She stated she informed S14WCS she would sign the orders for the supplies but would not sign for the wound care. She said she asked where the wound care nurse was getting orders from and no one was able to answer her. An interview was conducted on 11/23/2021 at 4:12 p.m. with S4DON. She said the weekend wound care would be completed by the floor nurse. She said weekend staff would know if the wound care nurses were scheduled because they would see her name on the staffing sheet. She confirmed on the weekend of November 13 and 14 the floor nurse would have been responsible for wound care. She confirmed the weekend nurse should initial when wound care was completed. She confirmed the wound care was not completed on the following dates; 10/16/2021, 10/17/2021, 10/18/2021, 10/19/2021, 11/13/2021 and 11/14/2021 by the nurse. She said for clarification orders typically it was the charge nurse but currently they did not have a charge nurse so it could be the floor nurse, DON or ADON. She said the floor nurses were aware they would need to clarify orders at night, evenings and weekends. For wound care orders, she stated the wound care nurse would complete the Treatment Administration Record (TAR) and the floor nurse would complete the MAR. She stated if there were no orders from the hospital the nurse would need to contact the MD for a verbal order. Sh [TRUNCATED]